HomeMy WebLinkAboutWater Street Cut Permits 112 Pheasant Wa APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
Amt. Bond Required '" PUBLIC WORKS DEPARTMENT }
Amt. on File ''"' .•' TOWN HALL Permit
Date of Expiration all 1540 SULLIVAN AVENUE Date "—?
1 Ins. on File es O No SOUTH WINDSOR, CT Permit Expires T'd 5
Expiration Date f VA, FEE $25.00 ff
Ingorporated„.,Con-9truc.tion.
Name of Firm --�
/,jgQrt woQ Drive, Bloomf'lpld - -242 01�50
Address of Firm �< Phone No :
Location of proposed work 1�12 P�3eaSa73 WaV- owner 'Boh Sel pia:
Describe fully nature of permitrequested tfis.ta11 new_water- zeryice L
Startingdate ,9-✓4/9 6
Approx. time for completion
Call before you dig No. 9 03-.5 9 2, Traffic Services Control No
Show sketch of proposed work or furnish To be idled out by Town of South Windsor
two copies of separate drawing
Pavement Cut
O Indicate North l
Prop. size of cut $ 10 _
No. cuts
Amt. of Deposit $_ Z09 b"qk
O Cash l ) 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
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 ules and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual.
y �
Signed. ,. _ ., --G, r Title: .ram
D.L.L.# r. .3 7 '7 Date:
PEF*ArT SHALL BE JOBSrTE AT A16L TIMES
APPROVED: DATE:
TOWN. E G R
FOR INSPECTOR: Date work started Date Completed
Signed Date
WHITE - PERMIT PINK - ST. SERVICES
YELLOW ENGINEERING "' "' GOLDENROD - FINANCE