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DescriP: ,7REET x
Scanr plal� R CHASE
Name CCX
C�JMMUN1.�A it�NS "Cy Kee of" it
Addr . U PARk R sT' ObO40 of Dona
MANCHPSTER Windsor the amount
Phone l U � s1 2-600C) slut expenses
the Townn,, OT r ..`for any t1 15
reel to furrr� Y� fl Quth YJiridsc� lunnect'on wit and
Apn i cant a9 h® Town ,. rePaI r wci1 1 n c . the rule"
to re-1mburse r r and y,t� 1 1 abide b=✓ � s street
requi r-ed and for` mainttenar �r r,dsot'
the Town i,s f ami"! a ofoc�tY� .j
incurred by IIcan't Erred rn the ,Town,._
permit and that app o.ut
ermits a
regu l at ntsManual
Cut Per TIMES .
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BE "KEPT
* PERMIT TO
TJIVle
Issued by _ tnsper t,ed by
Date Completed
y 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 C._O �(E Phone No.
Address of Firm I i Sei
Location of proposed work q /�a�eP c tiS�
Describe fully nature of permit requested o'
Starting date :13 7 Approx.time for completion Rilhie,
Call before you dig no. g 7,k(G0 2 3 r Traffic Services Control No. WJ9
Show sketch of proposed work or furnish To be filled out 6v Town of So Windsor
two copies of separate drawing Pavement Cut
Indicate North Prop.size of cut
No.cuts
Amt.of Deposit 8 by
�(3 i��✓ems .
,� h IZyc✓� O Cash O Check#
�i
Cut size after Perm. Patch
No.Cuts
Final Billing 8
Amt.Due Payee$
Amt.Due Town$
Applicant is responsible for contacting
the Police Dept.and C.B.Y.D. by date
I 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 1 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: �f Piet"eh D.L.# 13326 1.3A
PERMIT SHALL BE KEPT ON J013SITE AT ALL TIMES