HomeMy WebLinkAboutReplace gas service Street Cut Permits 5 APPLICATIC?N FOB TREAT.-EXCAVATION PE14MIT
7�- ,, :O - T. , WINDSOR
Amt. Bond Required PUBLIC I D pARTMENT
Amt. on File T WN MALL Permit Q
Oste of Expiration 1544 �„
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L11/AN.AVENUE Date
Ins. on Fie ( j Yes ( > No SOU E I$ CT Permit Expires
Expiration Date
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Name of Firm _� /l✓/�L�� �/i�.S
Address of FirmoSJpE"C phone No,
Location of proposed work _.3"O / ri'A--1,
Describe full nature of
Y Permit requested '
Starting date --
Call before you dig No. - !7x Y060 *('43 Approx. time for completion yE�
Traffic Services Control No.
Show sketch of proposed work or furnish To be tt®d out.by Town of f yy pr
two copies of separate:drawing
r
OPavement Cut
Indicate North
Prop, size of cut
No. cuts
}` Amt. of Deposit $ by
o S4 a r.
O Cash O Check #
Cut size after Perm Patch
No. Cuts
Final. Billing $
Amt..Due Payee-$
Amt. Due Town $
Applicant;is_responsible for contacting
the Police Dept. and C.B.Y.D. i
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 ' e.:by the rules and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual.
Signed: Title: / / Ci✓ /=it/G-
D L.L.# .9riLp TO one Date: 45'3"P'6
PEFWr SK&L 8E J0881ITE ATft
APPROVED:
DATE:_
OWN E R
FOR INSPECT ate work started Date Compl 1.eted
Signed Date
----LWH1-TS- PERMIT
YELLOW - ENGINEERING PINK - ST. SERVICES
;,.� GOLDENROD FINANCE