HomeMy WebLinkAboutDriveway Street Cut Permits West Road ne APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
Amt. Bond Required S" ) PUBLIC WORKS DEPARTMENT
Amt. on File �T�UU OWN HALL [Date_
ermit
Date of Expiration /z- I- 1540 SULLIVAN AVENUE .—'ZS-
Ins. on File (y'Yes ) No SOUTH WINDSOR, CT ermit Expires - ;_
Expiration Date S ' •�,{ FEE $25.00
Name of Firm _tJ / ii f' 1!J/)✓ f 1r,P1 5! 6/a
Address of Firm 1 ' f • :a o r l = iE'c !�� i 'fr a N iG. Phone No.
Location of proposed work A& S T Q o 1-)
Describe fully nature of permit requested A-1 TO �]�' V1> Z,
Starting date CO - .2 3 q-1 —
Approx. time for completion � 2 6 9S
Call before you dig No. `��3 ° a(l 1�' Traffic Services Control No.
Show sketch of proposed work or furnish To be tilled out by Town of South Wimb"
two copies of separate drawing Indicate North
O Pavement Cut
� J
Prop. size of cut Q
No. cuts
Amt. of Deposit $-. by
O Cash O Check #
I y'
Cut size after Perm Patch
No. Cuts
Final Billing $
Amt. Due Payee $ _.
_
Applicant is responsible for contacting Amt. Due Town $
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 wit and will abide by the rules and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual.
Signed: Title:_ (f! L; 1j 7f
Date:
PERMrT SWILL BE ON JOBSITE AT ALL TIMES
APPROVED: DATE:
ENGINEER
FOR. INSPECTOR: Date work started Date Completed
Signed Date
WHITE - PERMIT PINK ST. SERVICES
YELLOW - ENGINEERING GOLDENROD - FINANCE