HomeMy WebLinkAboutStreet Excavation Street Cut Permits Gov APPLICATION FOR STR "EXCAVATION PERMIT
TOWN OF SO WINDSOR
Amt. Bond Required PUBLIC WORKS DEPARTMENT
Amt. on File TOWN HALL Permit 2140
Date of Expiration 1540 SULLIVAN AVENUE Date
Ins. on File ( ) Yes O No SOUTH WINDSOR, CT Permit Expires
Expiration Date FEE $25.00
Name of Firm .v
Address of Firm ✓ ('c y �/ f ..r r,- 'i�`' C+ Phone No. -~- f
Location of proposed work
Describe fully nature of permit requested — Y!-4 •` _
StartingF i J�
date Approx. time for completion
Call before you dig No. ! t S ! '= ,+ Traffic Services Control No.
r `
Show sketch of proposed work or furnish To be filed out by Town of South VYhKIIS"
two copies of separate drawing
Pavement Cut
O Indicate North
Prop. size of cut
No. cuts
Amt. of Deposit $ N/ by
O Cash O Check #
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 v "
D.L.L.# Date:_`/�%a
PERMIT SHALL BE KEPT ON JOBSITE AT ALL TIMES
APPROVEDA/.i'r DATE:- q_&Af_
TOWN ENGINEER
FOR INSPECTOR: Date work started Date Completed
Signed Date
WHITE - PERMIT ` PINK - ST. SERVICES
YELLOW ENGINEERING GOLDENROD - FINANCE