HomeMy WebLinkAboutSewer tie in Street Cut Permits 38 Ident t _ -
APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WIN SOR
Amt. Bond Required .S. �'�` PUBLIC WORKS DEPARTMENT —
Amt. on File TOWN HALL Permit * ' p 192
Date of Expiration 1540 SULLIVAN AVENUE Date Q - 3
Ins. on File 00 Yes O No SOUTH WINDSOR, CT Permit Expires /V -�..
Expiration Date j- FEE $25.00
Name of Firm j -
Address of Firm �� Pho No.
Loc 'n of proposed work
Describe fully nature of permit requested—
Starting1 ' _ .,ice
date 3 p Approx. time for completion �
Call before you dig No 3 i v U Traffic Services Control No.
Show sketch of proposed work or furnish To be filed out by Town of South tfllfm bm
two copies of separate drawing
J �„J� Pavement Cut
O Indicate North 1/1�,A�� to
✓� co���� �J � Prop. size of cut ! 0Z lam,
U��N►� No. cuts /aq. x " J,U=
` Amt. of Deposit $ Q by
f
(vN -(A Cash
1 (*rtheck #—
f I A�� j►�1 1'i ( )
Cut size after Perm Patch
aa No. Cuts
Final Billing $
- - _ Amt. Due Payee $ -
Amt. Due Town $ .T
Applicant is responsible for contacting
the Police Dept. and C.B.Y.D. by date
I agree to funish to the Town ol South Windsor the amount of bond required and to reimburse the Town of South Windsor
for any expenses incurred y t Town for maintenance or repair work in connection with this permit and that I am
familiar with an ill abi e b tihe rules and regulations for permits as tlined in the Town of South Windsor's Street Cut Permit Manual
-AJSigned: Title: ✓��'
D.L.L.# Date:
PERUAfT SWILL BE ON JOBSA ALL TIMES
APPROVED: DATE: / .w ✓.. /
T NGINEER
FOR INSPECTOR: Date work started Date Completed
Signed Date
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