HomeMy WebLinkAboutGas Service Street Cut Permits Lot 1 Per APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
Amt. Bond Required PUBLIC WORKS DEPARTMENT
Amt. on File TOWN HALL' Permit
Date of Expiration 1540 SULLIVAN AVENUE Date
Ins. on File O Yes O No SOUTH WINDSOR, CT Permit Expires
Expiration Date PEE $25.00
Name of Firm
Address of firm i '�t Phone No. 7 3 Z!V S
Location of proposed work (:T_ / P-4 r Z r La
Describe fully nature of permit requested Go n 5"
Starting date - / - 9 S Approx. time for completion
Call before you dig No.95 3 0!0 19 7 G Traffic Services Control No.
Show sketch of proposed work or furnish To be titled out by Town of South Mii xhw
two copies of separate drawing
Pavement Cut
0 Indicate North
Prop. size of cut
No. cuts
Amt. of Deposit $ by
{ ) Cash O Check #
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 Perrrmlit Manual.
Signed: Lr;i n C+. 4 Title:d/t C Sure t/ in ka dC on
D.L.L.# Date: `�S
PB MtT SHALL BE KEPT ON JOBStTE AT ALL TWES
APPROVED: 17 ` DATE:
TOWN ENGINEER
FOR INSPECTOR: Date work started Date Completed
Signed Date
. WHITE - :PERMIT . - PINK- ST. SERVICES
YELLOW ENGINEERING i{:;rx+a=' GOLDENROD - FINANCE
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