HomeMy WebLinkAboutReplace gas service Street Cut Permits 3 (5) ,., AFC LEGATION ,FOIE: R' E�'.. XCAVATION PERMIT
TOWN SOU-TM Amt. Band Required iNiNDSOR
`` PUBIC WORK$uD`AEPARTMENT
Amt. on File F O LN f7/►*LL Q
Permit '
Date of Expiration _ rJ�a40: ULLLIVAN./A�VfENUE
Ins. an File OYes ( > Na SOUTH WINDSOR CT Date
Expiration Date FEE Permit Expires - f-
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Name of Firm
Address of Firm //a2 c l�'st f �
Location.of proposed work _ / L+ Phone No:
Describe fully nature of permit requested �`✓'� }!/ T/.�/Fi
-S"l,e_I 'L.-
Starting date 2 7-/ 9 b — SST G
Call before you dig Nq. Approx. time for completion
Traffic Services Control No.
Show sketch of proposed Work or furnish
by ` YVirtd�or
two copies of separate drawing To be idled out Town of $adh
Indicate 'North
Pavement Cut
Prop. size of cut
?W3 W No. cuts
Amt. of Deposit $ by
Cash ( j Check #
' Cut size after Perm Patch
No. Cuts
Final Billing $
-Amt. Due,Payee $ ---
_
Appiican is responsible for contacting Amt. Due Town $
the Polly Dept. and C.B.Y.D.
by date
I agree to funi to the Town of South Windsor the amount of bond required and to reimburse the Town of South Windsor
for any expehs incurred by the Town for maintenance or repair.work in connection with this permit and that I am
familiar with a will a e by the rules and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual,
Signed: Title:
D.L.L.# Date:_ / p 7S
PER Mrt SFfAtl BE KEPT ON 3TE AT ALL TIMES
APPROVED: DATE
ENGINEER
FOR INSPECTOR: Date work started
—
Signed Date
Si ned Date Completed
_- _1FATE-PERMIT
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