HomeMy WebLinkAboutWater Street Cut Permits 455 Foster Road APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
Amt. Bond Required PUBLIC WORKS DEPARTMENT —
Amt. on File TOWN HALL Permit 0
Date of Expiration 1540 SULLIVAN AVENUE Date
Ins. on File ( . Yes O No SOUTH WINDSOR, CT Permit Expires
Expiration Date . 4 FEE $25.00
Name of Firm TO C'-'✓l o"a -74Taf " ( LJc !iv• T 7'
Address of Firm' 12 AL-1-T-i-- :)It I: t Phone No.
Location of proposed work V ;5' &;A ttre_ ✓ ' ->
Describe fully nature of permit requested r I i. /t Ic a
Starting date Approx. time for completion
Call before you dig Noc�'� �..,�.Lcr ��FG�, Traffic Services Control No.
Show sketch of proposed work or furnish To be fated at* by Town of South Windsor
two copies of separate drawing
Pavement Cut
O . Indicate North
Prop. size of cut
No. cuts
Amt. of Deposit $_. by
Cash (, Check #
( j Cut size after Perm Patch
No. Cuts
Final Billing $
_ - 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 with an ill he rules and regulations for p its as outlined in the Town of South Windsor's Street Cut Permit Manual.
Signed: Title
D.L.L.# /C12 ct� cf y Date: cD Z;_, 1 (�
PERAArr SHALL BE ttEPrr ON JOBSfrE AT ALL TIIIIM APPROVED: ,. DATE: 16) — `1
TOWN ENGINEER
OFOR INSPECTOR: Date work started Date Completed •
Signed Date
WHITE - PERMIT PINK - ST. SERVICES
YELLOW - ENGINEERING GOLDENROD - FINANCE