HomeMy WebLinkAboutReplace gas service Street Cut Permits 5 (7) - ;
APPLI CATION. 01 .. t�EET `EXCAVATION PERMIT
Tp,WIV . i� SC1t7TH "VI/iN" 4F -
Amt. Bond Required P.U , IC.iNQ� DEPARTMENT "
Amt. on File TQf t MALL- Permit
Date of Expiration t540 SILLIVAN AVENUE Date .-
Ins. On File yes O]NO .S�UTI`I a*I N�$ A CT Permit Expires.~
Expiration Date FEE $ 0
Name of Firm , x �
Address of Firm-/IG►� /pi�crSl�+�G ? ,fi�i� c /Z� 2
Phone No.
Location of proposed work
Describe fully nature of permit requested A 11:151 /-V-10-100tG e (V_,A-C 19,�',V-f/!GAG:
Starting date ""/ 'P`� Q� 6P3 Approx. time for completion ! 3� �2
Call before you dig No. Traffic Services Control No.
Y
Show sketch of proposed work or furnish To be Ned cult by Town of Sou tlt VYindaor
two copies of separate drawing
Pavement -Cut
Indicate North
Prop, size of out
No. cuts
Amt. of Deposit $- by
d ' ✓.G O Cash O Check #'
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.S.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 ab' by the rules and regulations for permits as.outlined in the Town of South Windsor's Street Gut Permit Manual.
Signed: Title: P"A'C'r-o 'drNC ,
D.L.L.# 4 �tlSrJ�Date:
PEFOWTSHAILL BE JOBSUIE AT
APPROVED: DATE: �J
T N i EEI
FOR INSPECT Date work started Date Completed
Signed: Date
WHITE PERMIT. PINK ST: SERVICES z_
YELLOW ENGINEERING ' GOLDENROD - FINANCE