HomeMy WebLinkAboutReplace gas service Street Cut Permits 2 (3) io
APPLICATION fQ TN'EEl` CAV TION PERMIT
#YR _TOWN:,-6 Sq THt OR
Amt. Bond,Required PUBLIC WQ�AKupPA MENT
Amt. on File 4: TOWN. HALL Date of Expiratio Permit
AVENUE tf �• �540 SULLIVAN Dare �`---
Ins.: on File O Yes '~
O No SOUTH
INDS CT' Permit Expires /=
Expiration Date
Name of Firm - Yd4L lC W+ (90-S
Address of Firm "Phone No, a 1"-? •..2.2.5`'
Location of proposed work i3Oc,.4re~ /?A*
Describe fully nature of permit requested_ 0,010co¢C E
Starting date 6' • .Z 5/ " 6 —
Call before you dig No. Approx. time for completion
Traffic Services Control No.
Show sketch of proposed work or furnish To o be flilled pA by Town of S
two copies of separate drawing
Pavement Cut
Indicate North
Prop, size of cut
a 6-,!7— No. cuts
Amt. of Deposit $_. by
' O Cash { ) Check #
/G
Cut size after Perm Patch
No. Cuts
--------------------------
..5 Final Billing $
_. ,_ Amt. Due Payee $
Applicant is responsible for contacting 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 4willa by the rules and regulations, for permits as outlined in the Town of.South Windsor's Street Cut Permit Manual,
Signed: I / Gro
Title:- �itJ 67
tiO �Ofivsuw
D.L,I:: Dated S'-'3/ 9'6
PffoAfT SK4LL 113V ON AT ALL TIMES
APPROVED:
_DATE: -3/h,6
Nr GINEER
FOR INSPECTOR: Date work started Date Completed
Signed Date
----WHITE=_-PERMIT
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