HomeMy WebLinkAboutGas Street Cut Permits 887 Foster Street :.. — APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
Amt. Bond Required PUBLIC WORKS DEPARTMENT
Amt. on File TOWN HALL Permit 2171
Date of Expiration 1540 SULLIVAN AVENUE Dace ys _��.. tie
Ins. on File Oyes O No SOUTH WINDSOR, CT Permit Expires ..�'►-
Expiration Date FEE $25.00 �'"�—�
Name of Firm c "�
Address of Firm //17 A �� �N Phone No. 2?Z'2-234
Location of proposed work
Describe fully nature of permit requested V.4S ZO cLe _
Starting date Z+/ Approx. time for completion— 1 D24
Call before you dig No. 74 C Traffic Services Control No.
Show sketch of proposed work or furnish To be fEed out by Town of South tltlir>dsor
two copies of separate drawing
Pavement Cut d
O Indicate North
Prop. size of out
tsuj�!® No. cuts
ix b8 7 Amt. of Deposit $_ by
O Cash O Check #
C4S Smlil I os Cut size after Perm Patch
f 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 and will abide by the rules and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual.
i
Signed: /�Y+ ' Title:
D.L.L.# !' T 6 Date: .. ! d l
PB749T SHALL BE ITT ON JOBSITE AT ALL TiUIIIIES
APPROV `, ...pATE:
TER
4POR INSPECTOR: Date work started Date Completed
Signed Date
WHITE - PERMIT PINK - ST. SERVICES
YELLOW ENGINEERING GOLDENROD - FINANCE
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