HomeMy WebLinkAboutExcavate fire hydrant Street Cut Permits APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
Amt. Bond Required PUBLIC WORKS DEPARTMENT
Amt on File TOWN HALL Permit " .
pate of Expiration 1540 SULLIVAN AVENUE Date
Ins. on File O Yes O No SOUTH WINDSOR, CT Permit Expires
Expiration Date FEE $255.00
Name of Firms
Address of Firm H ,-r Phone No. f
Location of proposed work
Describe fully nature of permit requested eA GC � t (4
Starting date '67 � -� �! Approx. time for completion
Call before you dig No. Traffic Services Control No.
Show sketch of proposed work or furnish To be tilled out by Town of South Windsor
two copies of separate drawing
{ Pavement Cut
Indicate North
Prop. size of cut
No. cuts
Amt. of Deposit $ by
O Cash O Check #
Cut size after Perm Patch
No. Cuts
Final Billing $
Amt. Due Payee $ —
Amt. Due Town $
Applicant is responsible for contacting
the Police Dept: anti C.B.Y.D. by date
I
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 with and will abide by the rules and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual.
J / ! � 4
Signed:�/` , /� L7' J� ) Title: (.( (i[
D.L.L.# Date: �✓�'', "[/c j
PEPwif SHALL BE KEPT ON Jof3 m AT ALL -nws
APPROVED: DATE: - Z
TOWN ENGINEER
FOR 'INSPECTOR: Date work started Date Completed
Signed Date
WHITE - PERMIT PINK - ST. SERVICES
YELLOW - ENGINEERING i• I "" GOLDENROD - FINANCE