HomeMy WebLinkAboutRepair fire hydrant Street Cut Permits 6 APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
Amt. Bond Required PUBLIC WORKS DEPARTMENT
Amt. on Fife TOWN HALL P
ermit NO
Date of Expiration 1540 SULLIVAN AVENUE Ins. on File OYes O No SOUTH WINDSOR CTExpiration Date FEE $25.00xpires
Name of Firm �j J,
Address of Firm j Y" T,'-�
Phone No.
Location of proposed work 5 li f 1 ,v ) f
Describe fully nature of permit requested ( i Y
Starting date
Call before you �digo. j1 i~ Approx. time for completion 1 r c
Traffic Services Control No.
Show sketch of proposed work or furnish To be Idled aut by Town of South tfYindsor
two copies of separate drawing
j Indicate North Pavement Cut
Prop. size of cut
No. cuts
U
Amt. of Deposit $ by
O Cash O Check #
Cut size after Perm Patch
No. Cuts
' j Final Billing $
W Amt. Due Payee $
y. 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 Towr 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 wiithh and will abide by the rules and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual.
Signed:
Y L A Title
:
D.L.L.# Date:
PERMIT %TALL BE !ET�OjN JOBSITE AT ALL TIMES
APPROVED: /�-DATE:
TOWN ENGINEER
FOR.INSPECTOR: Date work started Date Completed
Signed Date
WHITE - PERMIT PINK ST. SERVICES
YELLOW - ENGINEERING GOLDENROD - FINANCE