HomeMy WebLinkAboutReplace gas service Street Cut Permits 2 (4) RE
APPLICATION FOR''.STAE T} dAVATI.ON PERMIT
TOWN OF .SO.U�'H ViIINDSQR
Amt. Bond Required 5i PU754
IC WO 1R�K-S*DEPARTMENT
Amt. on File 1 �11tl;N: 17L
Date of Expiration_ Permit
0 SULLIVAN A�ENUE Date
Ins. on File ( � Yes SOUTH 1NINDSOR CT
O No 9. Permit Expires
Expiration Date F E � r ~
Name of Firm dc.0 x
Address. of Firm i_ /SfIGG
Phone No.
Location of proposed work
-
Describe fully nature of permit requested— -40—a xYS 7rti`^ %r n �
�,r45' .SSE'.C.✓!G.c� w/THY � /iv • ____=�.c.Y�s"r�C. .'
Starting date
Calf before you,dig No. Approx. time for completion
Traffic Services Control No.
Show sketch of proposed work or furnish To toe Ned ouR by Town Ot South Yon
two copies of separate drawing
Pavement Cut
O Indicate North
Prop, size of out �J/4
No. cuts
��pS
Amt. of Deposit $ by
{ ) Cash O Check #
—Jed a '` -r S o2 vlGi' Cut size after Perm Patch
No. Cuts
Final Billing $
Amt.-Due-`PAyLire'_$
�'. 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 7 am
familiar with and will ab'de by the rules and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual
Signed: Title: C-il/c
imCvrlA.�� ,?ost�s�v
D.L.L.# Date:
PEF*AIT SMALL BE KEPT ON ,JOBSITE AT ALL TIIYF_S
APPROVED: DAT17.7 6
N ENGINEER
FOR INSPECTOR: Date work started Date Completed
Signed Date
—WHITE =PERMIT
YELLOW - ENGINEERING PINK > ST. SERVICES'
GOLDENROD FINANCE