HomeMy WebLinkAboutDriveway Street Cut Permits 222 Oak Stre APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
Amt. Bond Required 5:,0j60 PUBLIC WORKS DEPARTMENT —
Amt. on File r n 0 O TOWN HALL Permit 2 2102
Date of Expiration i'1• i-Rf 1540 SULLIVAN AVENUE Date - 2. , . .a
Ins. on File �[j Yes O No SOUTH WINDSOR, CT Permit Expires _*L—
Expiration Date/_'.rj- _ FEE $25.00
�J D .S l R R� Gr O D
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Name of Firm .5
n� _ou
Address of Firm /Z I t f l Al So ze le, d E IC e A Z) ..•�" !'—phone No. �' J '—,T.7, 6
Location of proposed work .2 .7— 0 A _
Describe fully nature of permit requested a S.'4 i/ Ale LJ
Starting3- Z l-/- ` 6' ' y Z 4/- 9'.6"
date g.�f� /c� � - Approx. time for completion
Call before you dig No. I Traffic Services Control, No.
Show sketch of proposed work or furnish To be Mod out by Town of South Words"
two copies of separate drawing ^
Pavement .Cut �� �.�i'l
O Indicate North "
Prop. size of cut J
6 R
No. cuts
i
Amt. of Deposit $ by
n D.,
�� IJ;!- ( ) Cash O Check #
LAB
Cut size after Perm Patch
lNo. Cuts
Final Billing $
Amt. Due Payee $ —
Amt. Due Town $
Applicant is Moon;ible-75—rcontacting
the Police Dept. and C.S.Y.D. 14 [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 .end will abide by the rules and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual.
Signed: Title:
D.L.L.# 7 Z � �a Date: S /s
PEfiMtr SW4LL BE ON JOBS(rE AT ALL TINES t APPROVED: DATE: l Z l/ /G�
..r
T= ENGINEER
5 FOR INSPECTOR: Date work started Date Completed
Signed Date
WHITE - PERMIT PINK - ST. SERVICES
YELLOW - ENGINEERING GOLDENROD - FINANCE