HomeMy WebLinkAboutStreet Cut Permits 818 Sullivan Avenue (3) G°NKecrc`r
STATEOF CONNECTICUT
DEPARTMENT OF TRANSPORTATION ` �S
I l 0 BUREAU OF HIGHWAY OPERATIONS AND
`�Cru, "-eJAI 4�
°F raP t MAINTENANCE
Date: PMT-1 Rev. 10/13 Application form must be filled in
04/29/2014 State of Connecticut completely and mailed or delivered
Fee: (far DOT use) Department of Transportation to the corresponding District
APPLICATION FOR PERMIT Office for the subject town.
LOCATI _PA)SED WO --
South wmdsar 194 81S Sullivan Avenue
(a) Town _______.._�....�jnd _ ._.. ..,.:.r(b) Route .__._,___..... (c) Street Name &No. ......
d Circle One S. E. W. side of Highway e Located Between Utility Poles No. & No. ...
60.00. {
(f) Distance and direction from nearest intersecting road ,._._.. .._._..��'�lbidLm(N. S.�E�W.) of
Application is hereby made to:(Describe fully& include sketch or attach plans)
Excavate to repair broken sanitary sewer main pipe
1
P � i
PERMIT FEE can be paid only by check or money order payable to Treasurer- State of Conn.
In' Cnmrry & an3o ts�� �_ Permit to be issued to:
j Town of South Windsor
Name ........... ....... .................. ._ ..... . _....
i Party whom Bond is issued:
&
Print Name
i 1540 Sullivan Avenue
i Address ------ ----_-----
i Signed Phone ;
Town
South Wind
06074
J
Party to whom Insurance is issued:
The owner of the property for whom this work is
Print Name being performed agrees to accept all future
maintenance responsibility for the work specified in
Signed the permit.
Town of South Windsor
Approximate Time Required Desired Starting Date Print Owner's Name _.....-,.. .._..._..._..._.ry _..__._._.___...._._
i -
-- Address
1540 Sullivan Avenue,SW CT 06074
Complete Plans and Specifications must be submitted Sign Phone G,, - I '1 ,
for major encroachment permits. On other work a
j careful sketch shall be shown on space above or on
backside of application. 1�AtApd -<x
If -Rev.10113 P , a 3 & otJ
4
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S $ A T E O F C O l�f 1� E C A I C tJ T
ti DEPARTMENT OF TRANSPORTATION
BUREAU OF HIGHWAY OPERATIONS AND /I o Cr "
gyros rR MAINTENANCE ! l'��67aQ(d
Date: PMT-1 Rev. 10/13 Application form must be filled in
State of Connecticut completely and mailed or delivered
Fee: (for DOT use) Department of Transportation to the corresponding District
APPLICATION FOR PERMIT Office for the subject town.
L0CAT
a)Towns South windsor ^_ b Ro to ,194 . c Street Name &No. .�18 Sullivan Avenue
( ) ( ) ( )
(d) (Circle One)UN S. E. W. side of Highway (e) Located Between Utility Poles No. _ &No. �}/_
660.00
(f) Distance and direction from nearest intersecting road -- �-m �!M.TkM(N. S.O Tro W.) of X'__,__1 tJRd)
Application is hereby made to:(Describe fully &include sketch or attach plans)
Excavate to repair broken sanitaiy sewer main pipe
PERMIT FEE can be paid only by check or money order payable to Treasurer- State of Conn.
1313t of Bond Permit to be issued to:
Town of South Windsor
Name
Party whom Bond is issued:
Print Name [1�� Sullivan Avenue
Addressu M.r .__
Signed Phone
Town South Wind P 06074 1
Party to whom Insurance is issued:
The owner of the property for whom this work is
Print Name being performed agrees to accept all future
maintenance responsibility for the work specified in
Signed the permit.
JA roximate Time Required Desired Starting Date Print Owner's Name Town of South Windsor
pP q g
I /� /I LI Address kL40 Sullivan Avenue, SW CT 06074
Complete Plans and Specifications must be submitted Signw"4 M. , Phone
for major encroachment permits. On other work a
careful sketch shall be shown on space above or on
backside of application. i�x
I—Rev. I0/13 qk P le an M-0- G Cf,, 5�h e�l�G Q /Z 4% 3
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Date.Printed:5/21201:4
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MAP DISCLAIMER-NOTICE OF LIABILITY Approximate Scale:1 inch 40 feet .
This map is for assessment purposes only.it is not for legal W -
description or conveyances.All information is subject to verification by
any user:The Town of South Windsor and its mapping contractors 40
assume no legal responsibility for the information contained herein. Feet S
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http://southwindsor.mapxpress.net/ags_map/printmap.asp?extentYmin=869780.2499999999... 5/2/2014