HomeMy WebLinkAboutRepair broken water main Street Cut Perm (13) APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR _)
Amt. Bond Required PUBLIC WORKS DEPARTMENT
Amt. on Fife TOWN HALL Permit • N2 1
Date of Expiration 1540 SULLIVAN AVENUE Date
Ins. on File O Yes O No SOUTH WINDSOR, CT Permit Expires�
Expiration Date FEE 25.00
Name of Firm confl . - 1 - (to -
Address of Firm r r ylq
/ Ic Phone No. i� v�'.�J JI`
Location of proposed work
Y
Describe fully nature of permit requested i r f` to r
Starting date !�-eu Approx. time for completion l�
Call before you dig No. Traffic Services Control No.
Show sketch of proposed work or furnish To be filled ad by Town of South Wf Kkm
two copies of separate drawing
�../ Pavement Cut
Indicate North
Prop. size of cut
No. cuts
Amt. of Deposit $ by
' O Cash O Check #
Cut size after Perm Patch
f5�
No. Cuts
Final Billing $
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 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.
Signed: lj[I.(lJL.( L i AA Title:
D.L.L.# Date:
PERMfr SWW_ BE-KEPT ON JOBSrfE AT ALL TIMES
APPROVED: J� 1�� DATE: 27
TOWN ENGINEER
FOR INSPECTOR: Date work started Date Completed
Signed Date
WHITE - PERMIT PINK - ST. SERVICES
YELLOW - ENGINEERING GOLDENROD - FINANCE