HomeMy WebLinkAboutSewer Lateral Street Cut Permits 112 Phe a
APPLICATION FOR STREET EXCAVATION PERMIT
} 16— Lp OR SO TH.�/INDSOR
Amt;}Bond Rsquire PBS W( R DEPARTMENT
TOWN HALL Permit -
Amt. on- le ' ?
ate of Expiration -/ 7 1540 SULLIVAN AVENUE Date_ ,(i /Qt
Ins.'on File ( t),�(es.y O No SOUTH WINDSOR, CT Permit Expires
Expiration Date 7-7-1 Ih FEE $25.00
Name of Firm �lU�a"d
Address of Firm - �7 %��tr✓d / "!/ a' � Phone No. AKO gig
Location of proposed work 0W,-,45 ,Vr &VA S�
Describe fully nature of permit requested 24)S 'n/
Starting date 6' / Approx. time for completion A
Call before you dig"No. ��0�9�d Traffic Services Control No
Show sketoh of proposed work or furnish ',r,, '36--'W fiNed out W TbGMiCO2
South'VVi or
two Copies of separate drawing
Pavement.vtut A_. ..
Indi" arSh .�..
_ Prop. size of out
No. cuts
� g /
Amt rt of Deposit $F�'�':5�- s,',PYl-�-a---..
r,.-, z; .✓ ( ) Cash (0Check #
Cut size after Perm Patch
No. Guts
Final Billing $
�.rl' + /y/ � I�".�. i+�r. ,,,�e�^,�r�IrF/.w. � G:✓'�t''",. .a6 roc•m✓
I / ! Amt. Due Payee $
•Adm - ' c•}c+E �i4�dq./r"",ir�+ i��ls�' -'e. .rg,��•'tr - _ - .r't�(:1���11r .r-,'
Amt. Due Town $ f f
Applicant is res pnsibie for contacting
+� �'P the PdKcIr De pa t'G` .Y.t `� c t .r . ,�r�-s.i.3 .h- �► by . Y ti' date Vic",✓ G r � ' r,
i atFafiljhfRe Toyrn.,-of Sout�i Windsor. the ampurlt,,of, bond required and to reimburse the Town of South Windsor
forkn,Y afls )fletarrd by the Town for maintenancg-or repair work in connection with this permit and that I am
�fICaf h:Y WI a;by tffe rules arid -regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual.
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it3rk istarted Date Completed
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'WHITE PERMf t PINK - ST. SERVICES
Y-ecLE?W (ICI i1NG ,,,
GOLDENROD FINANCE. -