HomeMy WebLinkAboutReplace gas service Street Cut Permits 4 (8) APPLICATION f0 STiET EXCA1/ATtON PERMIT
TOWS( OF SUTH V1i1NDS°OR
Amt Bona Required PUBIC-. WORKS DE -NT
Amt. on File -ow
MALL 1
Date of Expiration Permit
SRUTH
�1LLI AVENUES.
Date .. 0-.
Ins. on File O Yes O No WIN.
Expiration Date 0 I VT Permit Expires ..
FEE
Name of Firm
Address of Firm--.. ZIA P/1 oS,�t�?-
Location of proposed work Phone 'No.
Describe fully nature of permit requested RAF,004Ac F
X 7/C G`i9S 'cc r c�i 7if / A-0
Starting date 7'/""9 6
Call. before you dig No. NO 03 Approx. time for completion
Traffic Services Control No.
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Show sketch of proposed work or furnish To be ldbd out by Town of Spy
two copies of separate drawing
Pavement Cut
Indicate. North
Prop. size of out �j ba,
t v No. cuts
Amt. of Deposit $: by
O Cash O Check #
sc t4V G
Cut size after Perm Patch
No. Cuts
Final Billing $
.Amt. Due•Payee .$.
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 b the Town for maintenance or repair work in connection with this permit and that 1 am
familiar with and will abide by the rules and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual.
Signed: Title: /Ec r� tiG-
D.L.L.# .4ym;,vrrv� TUf/w�o�Y Datec-- -.3-,9 6
PERWT SHALL BE KEPT AT ALL
APPROVED: DATE:_
TOW: ENGI
FOR INSPECTOR; t work started Date Completed
Signed Date
'- -WHITE-=PERMIT
YELLOW - ENGINEERING PINK ST. SERVICES
GOLDENROD FINANCE