HomeMy WebLinkAboutReplace gas service Street Cut Permits 3 (4) APWLICAfiION 'FO
S� RErt` ,�yATION PERMIT
TOWN O SOUTH WI�IDSOIR
Amt. Bond Required PUBLIC. W KS :DEPARTMENT _Amt. on File -- 3
Permit ' 0` 8
Date of Expiration_ "�54Q SILLN AVENUE
Ins. on pile { } Yes { } No SOUTR WINDSO CT Date S
Expiration Date__ F�E Permit Expires
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Name, of FirmM _ S '1
Address of Firm_LLQ? ReQ sf'.EC?' /_, J
Location of proposed work 2 � 3 Phone No.
�/v /2 AO i
Describe fully nature of permit requested_ laGs4C .F 1!/Sits
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Starting date - 7—ee 7'i6
Call before you dig No. Approx. time for completion
Traffic Services Control No.
Show sketch of proposed work or furnish
two copies of separate drawing Ta idled out Town of Syufh y
Pavement Cut
.Indicate North � •�+
3 Prop. slze of cut 1
�33
No. cuts
Amt. of Deposit $_. by
} Cash { } Check
Cut size after Perm Patch
No. Cuts
�'Y�s riv 6- iw
Q. Final Billing $
Amt. Due ,Payee,S
-_
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 and will a 'de by the rules and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual,
Signed: Title:
AZ,¢ 70riasv.+i
D.L.L.# - Date:_ '
PER W SHALL BE ON_JOMM AT ALL TI M
APPROVED: DATE: 3ih4.
TOWN. EER
FOR INSPECTOR: Date work' started
Date Completed
Signed Date
-- WHITE_ P_ERMJT.
YELLOW - ENGINEERING PINK ST. SERVICES
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GOLDENROD - FINANCE
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