HomeMy WebLinkAboutReplace gas service Street Cut Permits 5 (4) APPLICATION FOB STRE'T`EX'CAVATION PERMIT
TOW WO SOUTH VINDSOI .
Amt. Bona Required PUBLIC.Wflll DE AR
Amt. on File TOW HALL Permit • Q
Date of Expiration 1540 SULLIVAN AVENUE Date
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Ins. 'on File OYe O No SOUTH WINDSO. CT Permit Expires
Expiration Date FEE :
_Name of Firm 901PL
Address of Firmone No. � �-
Location of proposed work / G i2
D)sseribe f Iiy nature of permit requested. �f��i�EG�
Starting date Approx. time for completion /Y�/�
Gall before you dig Jdo. P� oG0 �03 Traffic Services Control No.
Show sketch of proposed .work or furnish To be Piped OW by Town of SaAh yy#nd
two copies'of separate drawing
Pavement Cut
. Indicate North } '
Prop. size of cut �f
No. cuts
Amt. of Deposit$_ by
O Cash O Check #
Cut size after Perm Patch
r
No. Cuts
Final Billing $
j 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 abide the rules and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual. :'
Signed: Title: J / 4
D.L.L.# s!/9yti� ,�s3Or/Date: 613
PealNff SHALL BE ON DIBSITIE AT
APPROVED: DATE:_ 6 "'^4-
OWN f f E R.
FOR INSPECTOR: Date work started Date Completed
Signed Date
------WHITE---PERMIT _
PINK - ST., SERVICES
YELLOW ENGINEERING GOLDENROD - FINANCE