HomeMy WebLinkAboutGas Service Street Cut Permits Ident Roa API!6CATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
Amt. Bond Required PUBLIC WORKS DEPARTMENT —
Amt. on File TOWN HALL Permit * N2 213"
Date of Expiration 1540 SULLIVAN AVENUE Date
Ins. on File O Yes O No SOUTH WINDSOR, CT Permit Expires
Expiration Date FEE $25.00
Name of Firm Q f1�<4LgL ( s=Z) S<a.c v i CGc2 c C0 .
Address of Firm !t Z f1,`+� ez -- NN�e\ —N Phone No. Z9 2-'Z Z 45
Location of proposed work ic�o 11 4 RC_j
Describe fully nature of permit requested ''T-_,-7 j '472 6,0_5 l4Q r" r 6o S Se l y i IC 1Z
Starting date 7 !`� !"�.S'' Approx. time for completion C Yea a r"
Call before you dig No. 'i 5 ZF3 Q 'L 5 jl� Traffic Services Control No.
Show sketch of proposed work or furnish To be filed out by Town of South Wnxkor
two copies of separate drawing
Pavement Cut
O Indicate North
`--�- �,T�/�t+��•�Sw?, Prop..size of cut
No. cuts
Amt. of Deposit $_ by
O Cash O Check #
Cut size after Perm Patch
No. Cuts
Final Billing $
Amt. Due Payee $ —. _,..
Amt. Due Town $ _
Applicant is responsible for contacting
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 abide by the rules and regulations for permits as outlined in the Town of South/Windsor's Street Cut Permit Manual
Signed: �7at7c7 9o!1 ��.�\ Title:J f�f t c2
D.L.L.# Date: 7�!
PERFAIT SHALL BE KEFFT ON JOBSITE AT ALL TIOAES
APPROVED:_- /O��f�Y DATE:
TOWN ENGINEER
FOR INSPECTOR: Date work started Date Completed
Signed Date
WHITE - PERMIT PINK - ST. SERVICES'+,,, .
YELLOW - ENGINEERING GOLDENROD - FINANCE 4'