HomeMy WebLinkAboutReplace sidewalk Street Cut Permits 211 APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
0Amt. Bond Required PUBLIC WORKS DEPARTMENT
, Amt. on File TOWN HALL PermAExpir
Date of Expiration 1540 SULLIVAN AVENUE Date5"
Ins. on File OYes O No SOUTH WINDSOR, CT Perm
Expiration Date FEE $25.00
Name of Firm MA Ali C VJV IAIC
Address of Firm 60C Al, Phone No. S7 ?7-1
Location of proposed work —ISO.
Describe fully nature of permit requested LF Q Ad? G9/ .�/Q�k/A..,
Starting date
Call before you dig No. LA147G• Approx. time for completion
Traffic Services Control No.
Show sketch of proposed work or furnish To be fi9ed out by Town of South VVhxk"
two copies of separate drawing
O Indicate North Pavement Cut /d
Prop. size of cut
/ No. cuts
/ Amt. of Deposit $ by
O Cash O Check #
M
Cut size after Perm Patch
No. Cuts
r � Final Billing $
Amt. Due Payee $
Amt. Due Town $
Applicant is responsible for contacting 3G
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 an ?,ide�:_ by the ru s and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual,
Signed: '^'"W Title:
D.L.L.# Date:
PER1iRT SHALL BE ItH'T ON AT ALL TIMES
APPROVED: DATE:
TOWN ENGINEER
FOR INSPECTOR: Date work started Date Completed
Signed Date
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