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Name H . W . LE'VACK CO. �A6i�°1`\T J�.�fi._tY
Addr . dS MAS(;OLO ROAO
SOUTH WINDSOR CT 'OT o, s- KA.i ER
Phone
Applicant agrees -,p ,fwrh1shi: ',the. "r6i4f1� +f indsor- the arriount of bond
r•equ i red and to re-(;Mbu rEe Cite.;. i`gw� :.fit. ; but n '�1'�C1$,or T,,,or any expenses
incurred. by the Tov;n fob`. rt+a�'iltenan "or re pa i r j4o► �a. , ,rn connection with this
permit and that app r.arit "�T"ar "z " .a� r7 1�.", ��d w I>1 ! its'.< e by the ru 1 es and
regulations for per nai cs` a's c ut � 1 nett i r the Tow:r� of South) W 1 nrlsor ' s Street.
Cut Permit Manual .
1."E R,M.!9. T C 1,�.E %K.�P-T :' `'S�T 1 A, M 1_L. �.1ti1 1.=S.. 7k m
Date Completed ........... _ --.- _ _ ._._ Inspected
APPLICATION FOR
OF SOUTH EXCAVATION PERMIT
PUBLIC WORKS DEPARTMENT
TOWN HALL
1540 SULLIVAN AVENUE
SOUTH WINDSOR, CT
FEE $25.00
! /
Name of Firm C'7 Phone No.
Address of Firm
Location of proposed work �' - ' 12
Describe fully nature of permit requested �'°�/ �=7'-
Starting date -7 Approx.time for completion
Call before you dig no. �i ;7/ Traffic Services Control No.
Show sketch of proposed work or furnish To be filled out by Town of So. Windsor
two copies of separate drawing Pavement Cut
i
Indicate North Prop.size of cut 6 X 9'
No.cuts
Amt.of Deposit by
O Cash O Check#
Cut size after Perm. Patch
4 No.Cuts
_ Final Billing $
Amt.Due Payee $
Amt.Due Town $
Applicant is responsible for contacting
the Police Dept.and C.S.Y.D. by date
1 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 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 PERMIT MANUAL.
F
Signed: �-9��v_�/ L�.� -C.I.. � Date:
r
Title:. D.L.#
PERMIT SHALL BE KEPT ON JOBSITE AT ALL TIMES
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