HomeMy WebLinkAboutGas Service Street Cut Permits 994 Pleas APPLICATION FOR STREET EXCAVATION P
Amt. Bona Required_ TOWN OF SOUTH WINDSOR PERMIT
Amt. on File PUBLIC WORKS DEPARTMENT
`Date of Expiration__ TOWN HALL �---
1540 SULLIVAN AVENUE Permit NO
Ins. on File tomes O No Date
, CT
Expiration Date '7 / SOUTH WINDSOR `
—/ 9L FEE $25.00 Permit Expires
Name of Firm ` 4A/ 614J+ y
Andress of Firm Z
Locaticri of L? 'L�.JI d t?.ta.t„
proposed work Phone No.
Describe f9lly nature of permit requested
3 q +c. qS "yfc�
Starting dad /O
Call before 'you dig No. Approx. time. for completion
t
Traffic Services Control No.
Show sketch of proposed work or furnish
o; copies of separate drawing To be filed aW fov Town ofSomumth yy
Indicate North _Pavement_ Cut
y
a `) Prop. size of cut
Rurb No. cuts -
*So4we W�'6f
CE Amt. of Depositby
$_ _
9
O Cash O Check #
aG-$t7N6 rwIiN
Cut size after Perm Patch
No. Cuts
pn, Final Billing $
- _ Amt. Due Payee $
MPIISant;is responsible for contacting Amt. Due Town $
the POlice Dept. and C.B.Y.D.
i by
` date
I agree to funish to the Town of South Windsor the amount of bond required and to reimburse the Town of Sou
for any expenses incurred by the Town for maintenance or repair work in connection with this permit and
familiar with and will abide by the rules and regulations for South Windsor
permits as outlined in the-Town of South Windsor's Street Cut Permit Manual,
Signed: /L�.t..Q /f
Title: w�� j[/
D.L.L.#
Date:
fT SQL � ONJOBSfTt` AT ALL POIES
OVEO: DATE:
TOWN ENGINEER
PECTOR: Date work started
Date Completed
Date
ERMIT
NGINEERING', PINK ST. SERVICES
j` GOLDENROD -:,FINANCE -
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