HomeMy WebLinkAboutInstall relief valve Street Cut Permits APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
Amt. Bond Required PUBLIC WORKS DEPARTMENT Permit
Amt. on File , —
Date of Expiration v
1540 SULLIVAN AVENUE Date
v-�
Ins. on File O Yes O No SOUTH WINDSOR CT
Expiration Date FEE $25.00 Permit Expires
Name of Firm l i(.i(� t ) 1 )% ("o
Address of Firm Chi ``�f { L._ I
Phone No. L�
Location of proposed work
Describe fully nature of permit requested
Starting date - -- --
Approx. time for completion
Call before you dig No. ' Traffic Services Control No.
Show sketch of proposed work or furnish To be tided out by Town of South Vyindsor
two copies of separate drawing
Pavement Cut
Indicate North r`
Prop. size of cut
1� f No. cuts
Amt. of Deposit $-. by
( ) Cash ( ) Check #
Cut size after Perm Patch
7 f _
No. Cuts
Final Billing $
Amt. Due Payee $
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 by the rules and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual.
Signed_Ll�i'. Title: / / L44, "r
D.L.L.# Date: " (
PERMrr SHALL BE KEPT ON JOBSfTE AT ALL TIMES
APPROVL//
`^ DATE: h (/
TOWN E iNEER
1
FOR INSPECTOR: Date work started Date Completed
Signed Date
WHITE - PERMIT
PINK - ST. SERVICES
YELLOW - ENGINEERING GOLDENROD - FINANCE