HomeMy WebLinkAboutReplace gas service Street Cut Permits 5 (8) APPLICATIQN. on
E�1TV-X%AVATION PERMIT
Amt. Bond Required TOWN OS1?'I WDSOR
PUB ,I� WORKS DEPARTMENT
Amt. on File
TOWN HAL&iNUE
----
Date of Expiration___ 1546 SULLIVAN A Per►nit Q
Ins. on File O Yes O No SOUTI I WIV*;,
! Datej
Expiration Date_ CT Permit Expires
FEE
Name of Firm "'PS
Address of Firm / /Z!g G
Phone No. 2 z-2 ZS" 2
Location of proposed work �'" f�/Q/ /2�p
Describe fully nature of permit requested G t,
Tip .11
i T ilvC.. S Sx�/t wi ei
Starting date, 7
Call before you dig No. PeX ood day Approx. time for completion
Traffic Services Control No.
Show SR tch of proposed work or furnish
be
two copies of separate drawing TO tKfed ° T Sai1h YYTindaor .
0
Pa vement Cut
Ff � Indicate North -
Prop. size of cut
No. cuts
Amt. of Deposit $-- by
O Cash O Check #
Cut size after Perm Patch
No, Cuts
Final Silting $
<. . _.._. t u
Amt; Due Pay ee"$ .
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 abialrby the rules and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit
Manual.
Signed: Title: .+9:7/.0-L,e ' �� t e,
D.L.L.# ivr,X Date:
� :PERWr SHALL BE'KEPIr JOBSUE -*L YAWS APPROVED: ..-
DATE:_
T ER
FOR INSPECTOR: Date work started
Signed Date Completed
Date
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