HomeMy WebLinkAboutDriveway Street Cut Permits 854 Foster S APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
Amt.`Bond Required " & PUBLIC WORKS DEPARTMENT
Amt. on File dcd TOWN HALL Permit
Date of Expiration NOruF 1540 SULLIVAN AVENUE Date '13
Ins. on File ( Yes No SOUTH WINDSOR, CT Permit Expires,-/3-
Expiration Date 6O/ FEE $25.00
Name of Firm eA P ^^ �� <�
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Address of Firm fS —Qo tit, t TL,�tl UD Phone No. .Z g
Location of proposed work +'� S "2 �'�• CX'�' .,�. Q C T
Describe fully nature of permit requested y C W q.
'Tems r^akZ e- " w ti A Do On qv Tt:) �—
Starting date erg "7C �d"�� 51'
Approx. time for completion I Y%A 0 t-4 (-I'% It-t-
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
�} Pavement Cut
O Indicate N h
l� 8
Prop, size of cut
CNo. cuts
P
Amt. of Deposit $ by
Cash
2 OCheck #—
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 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: Q .
D.LL.# 4f Date:_
PERMfr BEVR
AT ALL TIMES
APPROVED: DATE: 91� !� r
FOR INSPECTOR: Date work started Date Completed
Signed Date
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