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HomeMy WebLinkAboutGas Main Street Cut Permits 895 Foster S (2) APPLICATION FOR STREET EXCAVATION PERMIT VV TOWN OF SOUTH WINDSOR Amt. Bona Required PUBLIC WORKS DEPARTMENT Amt. on File TOWN 1540 SULLIVANAVENUE Date .;, "� 221 • Date of Expiration Z r Ins,},on File O Yes O No SOUTH WI T NDSOR, CT Permit Expires -/- � 97 Expiration Date FEE 25.00 i E,:. Name of Firm �.� Address of Firm �'�+ 0.1V: =�.'7`" �� + . .2 Phone No. Location of proposed work T' . .T. Describe fully nature of permit requested-. w ��? 1 tw► Y�s /C E " Starting date _� // P4 Approx. time for completion Call before you dig No. _ ©� br _ Traffic Services Control No. Show sketch of proposed work or furnish To be Ned out by Town of South WOnds& two copies of separate drawing Pavement Cut O Indicate North : Prop. size of cut j sf �+ No. cuts fM�W Amt. of Deposit $ by CA{' . r O Cgsh O Check # Cut size after Perm Patch No. Cuts J". Final Billing $ Amt. Due Payee $ — Amt. Due Town $ -_ Applicant.is responsible for contacting the Police Dept. and C.S.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 4%uth Windsor for any-expenses-incurred by the Town for maintenance or repair work_ in connection with this permit and that 1-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. Signed: Title: -mod[ D.L.L_# Date: PER FAIT SHALL BE ITT ON JOBSrrE AT ALL TIMES APPROVED: / T N ENGINEER FOR INSPECTOR:' Date work started Date Completed Signed Date WHITE - PERMIT PINK ST. SERVICES YELLOW - ENGINEERING " rP ` GOLDENROD - FINANCE