HomeMy WebLinkAboutReplace gas service Street Cut Permits 5 (2) Y,
APPLICATION, FO.RPTREET `EXCAyAT14N PERMIT
TOWN -QSQUTH WINDS OR
Amt. Bond Required________`
-VOA. 4 DEPARTMENT
Amt. on File TOWN HALL Permit '
Date of Expiration 15 0 S`�ULLIVAN AVENUE Date.
Ins. on File O Yes O No S UTn r1/INDS 5 CT
Permit Expiration Date Expires
. FEE
Name of Firm 5
Address of Firm .2 �'� UC�E�T /f/G< /2 iC r ' %.401 Phone No. .2
Location of proposed work r-_/ 5` /2
Describe fully nature of permit requested Aff 'A-Ly-C E �f9s $ �GifG.E �gfc�s Ify
ILL-/9'ST�►G
Starting date
Cali
9'6'3 000 03 Approx. time for completion
before you dig No. Traffic Services Control No.
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Show sketch of proposed work or furnish To be fiYpd aut by Town of South YYirbsor
two copies of separate drawing
Pavement Cut
Indicate North
Prop. size of cut
No. cuts
Amt. of Deposit $_ by
O Cash O Check
Cut size after Perm Patch
f ry No. Cuts
Final Billing $
Amt. Duo..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 by the Town for ,maintenance or repair work in connection with this permit and that I 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
000,
Signed: Title: . / 4r.7
D.L.L Of"A65,-Av Torf sow Date: 6-3 --19 46
PERIf SFWIi BE' ON AT A*YAIES
APPROVED; R �
DATE:
TOWN EN i
FOR INSPECTOR: Date work started Date Completed
Signed Date
-WHITE---PERMIT
PERMI7
PINK - ST. SERVICES
YELLOW - ENGINEERING "" `' GOLDENROD - FINANCE