HomeMy WebLinkAboutConduit Street Cut Permits 79 Pierce Roa APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
Amt, Bond Required PUBLIC WORKS DEPARTMENT
i File TOWN HALL Permit ^il 7 1
of Expiration 1540 SULLIVAN AVENUE Date
Ins. on File ( ) Yes ( ) No SOUTH WINDSOR, CT Permit Expires
Expiration Date FEE $25.00
Name of Firm '`
Address of Firm yQS �J P� 7 q 7+ r�i�v1-rat"' M'f rt3ne No.
Location of proposed work r �� =2 C d, r -�—
Describe fully nature of permit requested
Starting date _(� -��� � �� "" -- - — — -
Approx. time for completion
Call before you dig No. 14- Traffic Services Control No.
Show sketch of proposed work or furnish To be Mod out by Town of South Windsor
two copies of separate drawing
O Pavement Cut
-�. Indicate North
Prop. size of out _ X
t=—Xi I
No. cuts
- s ..�f .
— Amt. of Deposit vby
O Cash
(,.Check #—
Cut size after Perm Patch
No. Cuts
rt Final Billing $
Amt. Due Payee $ —.
i5
L� of 4,5 y 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 expense incurred by the T W`n'for maintenance or repair work in connection with this permit and that I am
familiar with ar9d will abide b e rules Ind regulations forpermits as outlined in the Town of South Windsor's Street Cut Permit Manual.
Signed:
.f Awala- Title:
D.L.L.# f f o� `J - Date: r / i C� 19"C
PEPWIT SHALL BE KEPT
,yON JOBStTE AT ALL TIMES
APPROVED: ? DATE:
�Y TOWN ENGINEER
FOR INSPECTOR: Date work started Date Completed
Signed Date
WHITE - PERMIT PINK - ST. SERVICES
YELLOW - ENGINEERING GOLDENROD - FINANCE
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