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APPLICATION FOR� TRE�T EXCAVATION PERMIT
TOWN OF" OUTH WINDSOR
Amt. Bond Required PUBLIC WORKS DEPARTMENT
Amt. on File TOWN HALL Permit � ^Z
Date of Expiration 1540 SULLIVAN AVENUE Date
Ins. on File K Yes O No SOUTH WINDSOR, CT Permit Expires
Expiration Date 7—ill FEE $24iiiil
Name of Firm E d'AS Address of Firm �/Z l�oSACs+ �' /�� �: Phone No. Z92 -ZA'%M Z+/
Location of proposed work
Describe fully nature of permit requested .wr GL
Starting date y „� �' /T 4T� Approx. time for completion 1 W K
Call before you dig No. 9� �/ * Traffic Services Control No.
Show sketch of lioposed work or furnish To be filled out by Town of South Windsor
two copies of separate drawing
Pavement Cut
O Indicate North
Prop. size of cut
r No. cuts
14 ..+200 Amt. of Deposit $ by
I
O Cash O Check #—
r 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 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: Lt7a 4".. Titli r�a s
D.L.L.# Date:
` r
PERMIT SWILL BE KEPT ON JOBS(TE AT ALL TIMES _
APPROVED:
TO ENGINEER s TT
FOR INSPECTOR: Date work started Date Completed
Signed Date
WHITE - PERMIT PINK - ST. SERVICES
YELLOW - ENGINEERING "' GOLDENROD - FINANCE