HomeMy WebLinkAboutReplace gas service Street Cut Permits 3 (2) APPLICATION _FO1 STRStaEVATiQN PERMIT
1
h TO N OF ND.SO�i Amt Bond Required_— PUB SOUTH Wh
IC WORKS .DEPARTMENT
Amt. on File TOWN HALL
Date of Expiration 1540 S.ULLIVAN AVENUE permit
Ins. on.File ( j yes ( � No SOUTH WINDSOR CT Date 3
Expiration Date_ FEE Permit Expires
Name of FirmN G $
Address of Firm /dkSf� 'G ,-� mot/
Location of proposed work_ C.^-/.�/��C/,,L Phone No. 9.2 - .Z ?
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Describe fully nature of permit requested 4/0C �!/ST/ivE�r
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Starting date ✓7 X 7 C, — ----
` Cali before you dig No. Approx. time for completion
Traffic Services Control No.
Show sketch of proposed- work or furnish
two copies of separate drawing To be fimd °.* Tom^ °f So+th 1Nirndsot
Indicate North
Pave_ ment Cut
Prop. size of cut
No. cuts
Amt. of Deposit $ by
vice O Cash
OCheck #—
` Cut size after Perm Patch
�'Sit t Ttti� �.e9 r
No. Cuts
8�
Final Billing $
Amt. -Due:Payee .
_
ARplicant 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 and will ab' a by the rules and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual
Signed: Q Titles.
�r/2,s1 ? ev ?OyeSd6it,I
D.L.L.# Date: 31
PEIAW SHALL BE ON JOBS91E AT ALL TRAES
APPROVED: DATE: '3I
T ENGINEER
FOR INSPECTOR: Date work started
Signed Date Completed
9 Date
--WHITE--.PERMIT
YELLOW - ENGINEERING PINK - ST. SERVICES
- - GOLDENROD - FINANCE