HomeMy WebLinkAboutGas Street Cut Permits 155 Niederwerfer b ll
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pCTrmi t`: NO. ? 1 Town of Sou`th Windsor , C:'l
Date i� �1 1 / # 3 '7 a S-Eree t Excavation Perm1 t
Expiration Date 06! 11 / 1998
Desci-1 p; t_0-F 17 CHASE FARMS
App I i cant t_( cat l on
Name rgh�F.cE i AS # 5 i�lEOER9�iER ER
Addr . f .4: . BOX 1030
MERIDEN C7 06450 # yp-' of Wr.)rrC GAS
Phone t,800 1969-G900
App l i caoL agrees to furni sh the "Gown Of Sot1,h W i ntisor the amo,,jnt of bcrsd
requ red and to r`eimbur'se tie 'Town o S9vth vd'ir7cfscPr ,,.or any expenses
incurred by the Town #For' Maintenance or repair' work: in lonrect10 with th"t5
permit and that app i i i',arar. is, f amp l i ar With and i 1 1 jt' de try he rules and
regulations for perrvl c as dutl ined Ir► the 'down oi" Soui-.•h w ndsor` s S1;r"eet
s
Cut Permit Manual .
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To BE rA, 81 A! AL
Issued b y i °i f, i F,
Date Camp +eteca _._
23//
APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
PUBLIC WORKS DEPARTMENT
TOWN HALL
1540 SULLIVAN AVENUE
SOUTH WINDSOR, CT
FEE $25.00
Name of Firm 6 % Phone No. 7-q'Z-zz S'I
Address of Firm
Location of proposed work e
Describe fully nature of permit requested E ,<< 2mn �":C-A -C V �Q
Starting date q Approx.time for completion
Call before you dig no. 9.7 Z301 a 16 Traffic Services Control No.
Show sketch of proposed work or furnish To be filled out by Town of So Windsor
two copies of separate drawing Pavement Cut
Indicate North Prop.size of cut
V
No.cuts
Amt.of Deposit$ by
/� (1 Cash()Check#
Cut size after Perm. Patch
No.Cuts
t (� Final Billing$
Amt.Due Payee $
Ap'Qrc x. Soo F} � Amt.Due Town$
Applicant is responsible for contacting
the Police Dept.and C.B.Y.D. by date
1 AGREE TO FURNISH 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: Date:
Title:- D.L.#
�r
PERMIT SHALL BE KEPT ON JOBSITE AT ALL TIMES