HomeMy WebLinkAboutWater Street Cut Permits 701 Governors H H
APPLICATION FOR STREETEXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
Amt. Bond Required PUBLIC WORKS DEPARTMENT —
Amt. on File TOWN HALL Permit ' NP 2152
Date of Expiration 1 540 SULLIVAN AVENUE Date
- Ins. on File OYes O No SOUTFHEE I DS T Permit Expires
Expiration Date
Name of Firm �"1" 4�iR l'�", ! t (sueii�►1 i"1 ff 4 f
Address of Firm 1 Z E i ► Phone No. ��
Location of proposed work
Describe fully nature of permit requested EmEAC-F-ncy i�spiai,� n L.: ^,Mll Lf'11F IZI,
Starting date f Approx. time for completion �d e`i IS
Call before you dig No. Traffic Services Control No.
Show sketch of proposed work or furnish To be filled out by Town of South VVlnn b"
two copies of separate drawing
Pavement Cut
O
Indicate North
Prop. size of cut
n� l
No. cuts
Amt.. of Deposit $ by
O Cash O Check #—
1 _ i 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
t �
Signed: 1 _ Title: y ' �` t �
D.L.L.# Date:
PERrAiIIT SHALL BE ON AlALL TINES C A NNE
APPROVED: DATE:_LV
TO GINEER
FOR INSPECTOR: Date work started Date Completed
Signed Date
WHITE - PERMIT PINK - ST. SERVICES
YELLOW - ENGINEERING GOLDENROD - FINANCE
a� -
_-THE METROPOLITAN DISTRICT
— 50-23
HARTFORD, CONN. - !
WORK ORDER APP.NO.
WORK ORDER NO. WRITTEN BY DATE W.O. OWNER NAME AND MAILING ADDRESS
CODE ? Kf
130849 .JMW—O 1� i a1%�'i 5 W it013EitT 1'L_OURCI � ^
ACCOUNT NO. PROP.LOCATION TOWN LOT# j,U 1 O O i ,—
14-01---104--0120-01 SO tdINDSOR SO WINDSOR CT ', i
SERVICE LOCATION TEL.NUMBER 06074
70:1. i:;CJ�:!E R)��[)� ;� i�WY — 701 GOVERNORS HWY
TRANSACTION CODE DATE AND TIME SCHEDULED CIS ACCOUNT HIGH SEWER
CODE STATUS SERVICE CODE
60 10/21/95: f '_i(-11a
INSTRUCTIONS
- - R j'
"�::.E��.tJ:Cf:;E: i...f�i��iK 1
REMARKS
I
i
T S K u c M S vD o N NO.
SERVICE DATE T r i E A / L I e i E SHUT OFF BOX
INFORMATION INSTALLED 5 E e o A S N E ; LOCATION
— WATER LAT. A A 'I 71 •`.f-I 'I 1 12 'i O 1 OFB 5
WATER H.C. .; Ij; f.;1.:) SDM
FIRE LAT. CSO
FIRE H.C. ASM
SEWER LAT. WSO
SEWER H.C. MSO 22 .0
CRL
EXISTING DATE TYPE SIZE MFG LOC SPECIAL MODE METER NUMBER 017r.FI DIG '
METER INSTRCT. OF RDG
NEW METER DATE TYPE SIZE MFG LOC NEW METER NUMBER ON READING
t�.
FINDINGS DATE PERFORMED TIME REPAIRED BY
CODE
f
i
RESULTS: I
tt
1
i
COST ACCOUNTING
SHEET:
FUND: a_0 DiV: rj'-;�j�y ACTIV: {ca 6'2'0 OBJ: 4?0 LOC: j r>r COND: 20
TRN/RSN: PROJ: PAYER:
J
CALL BEFORE YOU DIG 1-800-922-4455 C.B.Y.D.NO.