HomeMy WebLinkAboutCurb Cuts Street Cut Permits Lot 13 Kent APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
Amt. Bona Requires Sif?C)f/ PUBLIC WORKS DEPARTMENT
Amt. on File TOWN HALL Permit '
Date of Expiration -U-16 1540 SULLIVAN AVENUE Date_ zj—
Ins. on File ( Yes ( ) No SOUTH WINDSOR, CT Permit Expires:7—?.(1�
Expiration Date FEE $25.00
Name of Firm '
Address of Firm IF Phone No.
Location of proposed work
Describe fully nature of permit requested +— 1. 6:
Starting date U 1 f`7'7J Approx. time for completion
Call before you dig o. g '�� Traffic Services Control No.
Show sketch of proposed work or furnish To be tamed out by Town of SmM Wirtdm
two copies of separate drawing
Pavement Cut
Indicate North r
Prop. size of cut
No. cuts
Amt. of Deposit $ by
O Cash O Check #
Cut size after Perm Patch
/V No. Cuts
` v Final Billing $
1�1 Amt. Due Payee $
i
Amt. Due Town $ _—
icant i�sible for conta to
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 incu d by the�Towrl' r maintenance or rep ' wor connection with this permit and that I am
familiar with bide by`fie rules nd regulations for rmits outline n the Town of South Windsor's Street Cut Permit Manual.
Signed: Title: r
D.L.L. � 3aLlC'C!' Date: - �—
PERMff SHALL ON T ALL TIMES
APPROVED: DATE:
TO GiNEER
FOR INSPECTOR: Date work started Date Completed
Signed Date
WHITE - PERMIT PINK - ST. SERVICES
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