HomeMy WebLinkAboutReplace gas service Street Cut Permits 5 (6) i
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APPLICATION FO k_ 1'R ., EXCAVATION PERMIT
TOVI Q S :Amt. Band Required_ PUBLIC JUTM 'WINDSORDRTMENT
Amt. on File EPA
Date of Expiration_ WN ..A-
Permit
1540.SUL.LIVAIV AVENUE Date
Ins. on Foie OYes, O No SOUTF�VI/INDS T
Expiration Date Permit expires_:
Name of Firm
Address of Firm
Location of proposed work „� �,� �` P one No.
Describe ful!y nature of permit requestedF �GAGF fs'/S �,E,evie
f/ /N Jt9L
Starting date �"/"� _
Call before you dig No. 9'le 3 0o0 e03 Approx. time for completion 'A/L
Traffic Services Control No.
Show sketch of proposed work or furnish
two copies of separate drawing To.be °� Town Souk
Indicate North Pave_ mint Cut
Prop, size of cut
No. cuts
Amt. of Deposit $ by
v!M E/> 46 Cash
O Check #—
Cut size after Perm Patch
No. Cuts
Final Billing
Due Payee
,•.. , ;.. .. .,__ _ _ ._. _. _ . °:Arrtt."
Applicant is responsible for contacting Amt. Due Town $ ----T-
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 Winds Or
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 abi by the rules and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manuel
Signed:
Title:
D.L.L.#—�i i?!/l ea i�✓vso iy Date:—_
PBVAU S&Hi&LON •10HSt1 E p AU TMMES
APPROVED: g
DATE:
O GiNEER
FOR INSP OR: Date work started
Signed Date Completed
9 Date
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