HomeMy WebLinkAboutGas Street Cut Permits 370 Pleasant Vall T
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PERMIT
Inspected 6l
Issued by _----
Date 0ompleted ---
APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
PUBLIC WORKS DEPARTMENT utzsDa�/
TOWN HALL
1540 SULLIVAN AVENUE
SOUTH WIDSOR, CT
FEE $25.00
Name of Firm �1 A.VN K o-C2 C�r S Q Phone No. %Co 0 1 Z 9 2"I 1-S7
Address of Firm �\2rhf 11-1 4"'70 SN, n -s'o
Location of proposed work z "7 m � a--Q a 10-C ^\—�T a �'
Describe fully nature of permit requested —
Starting data 3 z 9_,_$ Approx.time for completion 6
Call before you dig no. 9l S cD g m 0 9 1 Ck Traffic Services Control No.
Show sketch of proposed work or furnish To be filled out by Town of So. Will'11dSor
two copies of separate drawing Pavement Cut
# 3r70
Indicate North Prop..size of cut
No.cuts
Amt.of Deposit$ by
(I Cash O Check N
Cut size after Perm. Patch
o No.Cuts
�.� Final Billirq$
.v Amt.Due Payee $
'4 Amt.Due Town$
Applicant is responsible for contacting
the Police Dept.and C.B.Y.D. by date
I 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 1 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.
Signed: Date: z/ Z¢5 A
Title: /C i ¢ D.L.#
PERMIT SHALLB XEPT ON JOBSITE AT-ALCTIMES-__- -_-_--