HomeMy WebLinkAboutRepair gate box for water system @ Avery APPLICATION FOR STREET EXCAVATION PERMIT
Amt. Bona Require 000 O N OF SOUTH WINDSOR
Amt. on File airs _ TOWN
WORKS DEPARTMENT
s U� TOWN HALL
Date of Expiration___ 1540 SULLIVAN AVENUE Permit � �
Ins. on File (t>n_s 6No
SOUTH WINDSOR CT Date -7 -
Expiration Date FEE $25.00 Permit Expires /2
Name of Firm s_T-0 6 c,. Sc V 1f S - ✓a
Address of Firm iU� U '� i, w-,, t4t
Location of proposed work f✓1B /00 hone No. -��� 6B�j ' S C� US
P � v ��-r�tu� Lti��
Describe fully n ure of permit requested Z11G :11", <--
, xc���ret. 0 fc. ,`
Starting date
Call before you dig No. �S y `i G I "? 1c6 Approx. time for completion �►U��"S
Traffic Services Control No.
Show sketch of proposed work or furnish
two copies of separate drawing TO filled °� ow, Town °( Sou� ypr
O Indicate North Pavement Cut
Prop. size of cut 4�
No. cuts L�
M P f Amt. of Deposit $ �d g/__/o
-�-0-' by
�( f?C �� f✓!� Q `"�..� ( ) Cash (-KCheck #�t4 �
Cut size after Perm Patch
I K No. Cuts
5 Final Billing $
�� � ��'IrP�
Amt. Due Payee $
,. Amt. Due Town $ ._
Applicant is responsible for contactin
9
the Police Dept. and C.B.Y.D.
by date
I agree to funi.sh to the Town of South Windsor the amount of bond required and to reimburse the Town of South Windsor
for any expe ses in cred by the w for maintenance or repair work in connection with this permit and that I am
familiar wit n will bide by , les and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual.
Sielm/ Title: �-7 'e
D.LL 1 !IL
' S�
Date:
I PE RMf T BE ON AT ALL TIMES
APPROVED: DATE:
T ENGINEER
FOR INSPECTOR: Date work started
Signed Date Completed
g Date
WHITE - PERMIT
YELLOW - ENGINEERING PINK - ST. SERVICES
GOLDENROD - FINANCE