HomeMy WebLinkAboutReplace gas service Street Cut Permits 4 Dv 1 t,3r aFt t q
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PLICATIQN FOt ' REE' '`,E)CCAVAT�ON PERMIT
TONS SQ"U7"H WIND OR
Amt. Bond Required
Amt. on File PUB ; IC WORK$ DEPARTMENT
bate of Expiration: TOWIN' HALL Q
p "5,4E . - L'.�.,IVAN .AVENUE Permit
Ins. on File c ) Yes No SOU .H WINDSOR, CT P Permit E '� — �o
Expiration Date FEE xpires
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Name of 'Firm �,144 "rAe al-o'
Address of Firm 4,/ — �@"p�i►�GT yip �G ,,�
Location of proposed worker 4 �,c,,a-cam, Phone No.
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Describe fully nature of permit requested_- End-/;i C/' ,�>e/S T/NG
if
. Starting date --
Call before you dig No. Approx. time for completion
Traffic Services Control No.
Show sketch of proposed work or furnish
two oopi.4 of separate drawing To tie
filled Town South YYindsor
Indicate North Pave=ie�t Cat
Prop. size of cut
Jq' No. cuts
COL-
Amt. of Deposit $
by
O Cash O Check #
Cut size:after Perm Patch
No. Cuts
Final Billing $
.�XiSTivF 4/PS �A�n✓
:rw Amt: Due .Payee $
r
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 wi bide by the rules and regulations for permits as outlined in the Town of South Windsor's.Street Cut Permit,Manuai.
Signed: r Title:
~47
Date:.
PEFUT SMALL BE ON JOBSITE AT ALL TIMES
APPROVED: DATE:_ ` I
T NGINEER
FOR INSPECTOR: Date work, started
Date
Signed Date Completed
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-WHIT.=-PERMIT
YELLOW - ENGINEERING PINK - ST. SERVICES
GOLDENROD - FINANCE
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