HomeMy WebLinkAboutReplace gas service Street Cut Permits 4 (4) APPLICATION FOtRE T ' IAVATION PERMIT
TOWN :OF SOTH W#NDSOR
Amt' Bond Required PUELIC iNRKS tEpARTMENT
Amt. on File . . .OWN PALL
ALL
Date.of Expiration 540 Permit ' `
$$ LLI1% N AVENUE Date ,
Ins: on File O Yes ( }.No SOU1�M:WI.NDS0 CT
Expiration Date Permit Expires
-�E E.
Nafie .of Firm �6�
Address of Firm 1/67- /�ieOs®EG% /y�GG w
Location of proposed work 4/ ,3 aQ/fjdjw x0 Phone No.
Describe fully nature of permit requested IF'�4vo G C AF, L
+9 S —rE.rt! /C Lv-�7/7' ► a?_ /�1.rr11'7%C
Starting date 6' `y'j' d'
Call before you dig-No. ApprOx. time for completion
Traffic Services Control No.
Show sketch of proposed work or furnish To be tided aut b✓Town of Soutl� 1AI[isor
two copies of separate drawing
Pavement Cut
Indicate North
Prop. size of cut
No. cuts
.3 Amt. of Deposit $ b
( } Cash O Check #
a edoio ors
rvri�� Cut size after Perth .Patch
No. Cuts
Final Billing $
.'Amt..,Due.Payee $
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 i am
familiar with and will a by the rules and regulations for,permits as outlined in the Town of South Windsor's Street Cut Permit Manual
Signed: Title:
lZI�1 N.� �d/`1�.4.fGLV
D.L.L.# Date: 3/�
PE uff SKLLL BE ON AT ALL TIIIIES
�II
APPROVED: DATE:
_93
TO N INEER
FOR INSPECTOR: pate work started Date Completed
Signed Date
YELLOW - ENGINEERING ,.,,.,. PINK - ST. SERVICES
GOLDENROD - FINANCE