HomeMy WebLinkAboutRemove sidewalk slabs/telephone repair S APPLICATION FOR .STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR'
Amt. Bond R�quyed PUBLIC WORKS DEPARTMENT
Amt. on File TOWN HALL Permit Q
Date of Expiration 1540 ,SUuLLIVAN AVENUE Date G
Ins. on File Oyes O No SOUTn WINDSOR, CT Permit Expires
Expiration Date FEE $2500
Name of Firm `/'13��' ako-eo.
Address of Firm +� -� N W14 -S j 7
Phone No. -
Lo.cation 'of proposed work 'a 1Iciu woGu. 'AZJb
Describe fully nature of f�ermit reues�Qd_ '`Em�V� -� ACC- t OL w a c ILG Y
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Starting date �� �- �� ----r��- +�� �—
Approx. time for completion
Call before you dig Na Traffic Services Control No.
Show sketch of proposed w fk or furnish
T_o be tilled +out j Town of SouthYVindsor
two copies of separate drawing
Ot Pavement Cut
.(�-- Indicate North &)o
Prop. size of cut
No. cuts
/ �
' > Amt. of $Deposit _
p by
'• O Cash O Check #
r
V� Cut size after Perm Patch
` No. Cuts
Final Billing $
E .
Amt, Due Payee $
Applicant is responsible for contacting
C 1 F"W O 0 Amt. Due Town $ _
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 arldwill abide by the rules ands;regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual.
Signed`. t ik Title: Hoq+✓
D.L.L.# Date: 1o%ff l9 r
RERMfT SMALL BE JOBSTTE AT ALL TINES
APPROVED: DATE: rU
TOWN E EER
FOR INSPECTOR: Date work started
Date. Completed .
Signed Date
"WHITE -'PERMIT PINK - ST."SERVICES
YELLOW - ENGINEERING "" GOLDENROD - FINANCE