HomeMy WebLinkAboutReplace gas service Street Cut Permits 5 (11) APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
Amt. Bond Required PUBLIC WORKS DEPARTMENT
Amt. on File 218
TOWN HALL Permit w,
Date of Expiration 1540 SULLIVAN AVENUE Date
Ins. on File O Yes O No SOUTH WINDSO CT Permit Expires -
Expiration Date FEE $
Name of Firmy
A/
Address of Firm --�� �� Phone No. 2 �-
Location of proposed work -
Describe
�� fully nature of permit requested /-2 /-11`:1G.r9
Starting date — �i�`� d ---- --------------------- ------ � � --
csoc� 6o Approx. time for completion Z
r=
Call before you dig No. `�6 3 3
Traffic Services Control No.
Show sketch of proposed work or furnish To be filled out by Town of South Windsor
two copies of separate drawing
Pavement Cut
O Indicate North
Prop. size of cut
t
t) No. cuts
i
3 Amt. of Deposit $_. by
f ! ( ) Cash ( ) Check #—
Cut size after Perm Patch
. di G�'_
S n/ No. Cuts _
- -- Final Billing $
Amt. Due 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.
Signed: �_- Title:_ /G/,F G� ,ryG
D.L.L.# /z- te: 9---j --"Q.
PERMI-r SHALL BE ITT AT ALL S
APPROVED: -DATE:'Ll-2 —4
TO N GI� E
FOR INSPECTOR: Date work started Date Completed
Signed Date
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