HomeMy WebLinkAboutGas Main Street Cut Permits 895 Foster S APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
Amt. Bond Required PUBLIC WORKS DEPARTMENT
Amt. on File
TOWN HALL Permit 2223
Date of Expiration__ � J. ; ` '154 SULLIVAN AVENUE Date_- 7_z - 9 orIns. on File O,Y,es O No so'. TH WINDSOR, CT Permit Expires '-/- pT
Expiration Date
FEE $25.00
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Name of Firm _4G,11<Er U44-
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Address of Firm— JA✓, Phone No.
Location of proposed work
Describe fully nature of�permit�requested
Starting date Approx.
�O/D6� time for completion
Call before you dig No. Traffic Services Control No.
Show sketch of proposed work or furnish To be idled out by Town of Sm h Windsor
two copies of separate drawing
Pavement Cut ������41
O .Indicate North
Neasa- Prop. size of cut
p Q� No, cuts
/IVir}W
f L
Amt. of Deposit $_ by
Q 3'
yro� O Cash O Check #
Cut size after Perm. Patch
No. Cuts
M/}%N f � Final Billing $
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` Amt. Due Payee $ —.
Amt. Due Town $
Applicant is responsible for contacting
the Police Dept. and C.B.Y.D. by date
I agree to funish to the Town of South Windsor the amount of bond required and to reimburse the Town of South Windsor
for any expenses incurred by the Town for maintenance or repair work in connection with this permit and that I am
familiar withhaand will abide by the rules and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual
Signed: : Title:W1
D.L.L.# Date:
PERMfT SHALL BE ITT ON JOBBSS(TE. AT 'ALL TIMES
APPROVED` _ G �r y� TE:
TOVIN ENGINEER
FOR INSPECTOR: Date work started Date Completed
Signed Date
WHITE PERMIT PINK - ST. SERVICES
YELLOW - ENGINEERING GOLDENROD - FINANCE