HomeMy WebLinkAboutExcavate at fire hydrant in grass Street APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
Amt. Bona Required PUBLIC WORKS DEPARTMENT
Amt. on File TOWN HALL Permit 1
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 r4r, 14,c,
Address of Firm -Phonp No.
Location of proposed work T
Describe fully nature of permit requested �_ Ca" f
Starting date ,1: ` 1 j Approx. time for completion
Traffic
Call before ou cfi
Y 9 Servi ces Control No.
Show sketch of proposed work or furnish To be Ned out by Town of South Wkxtw
two copies of separate drawing
Pavement Cut
Indicate North
Prop. size of cut-
No. cuts
�j Amt. of Deposit $_ by
O Cash O Check # '
f 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.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 IV 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: (,l I t1l
D.L.L.# Date: pj�- ,`,
PERmFT SMALL BE KEPT�ON joBsFrE AT ALL TIIYfirs
APPROVED: DATE:
y /! /// ` T
TOWN ENGINEER
FOR -1NSPECTOR: Date work started Date Completed
Signed Date
WHITE - PERMIT PINK - ST. SERVICES
YELLOW - ENGINEERING V GOLDENROD - FINANCE