HomeMy WebLinkAboutDrain Layers Permit Pleasant Valley Road (5) a,- •:..- ..,. a = ` -. .K [ _.. ..,, �' ..- -
' a . Q 333
'0ND y TOWN OF SOUTH WINDSOR
Am't Req. PUBLIC WORKS DEPARTMENT Date 3 ` Z`t -UG
TOWN HALL
Am't on File 1540 SULLIVAN AVENUE Permit No. '
` SOUTH WINDSOR, CT 06074
Date of Expiration Permit Expires y-r.H-*G
:APPE$o oTION FOR PERMIT
Name and address of applicant MIU,-i-1ELL, _-MvCk--jA)r. Phone No.
Rio C'SRo�bcF 1�•�� s`r� moo, w� i�(Js��� c-Y-
Location of proposed work .SA17-C--R Sz:c P4=-A�/j�-r- V.4uL�V`f (:PAfJ
Cr
Describe fully nature of permit requested c, --
S R v��✓L L fi►T'c- AL-, N SO—
Gt S o a; & e.. wH5g., �l
/Insurance on file with Town es no Date policy expires
Name of Insurer ::E7,4,1GYL ssJ e_
.o Approximate time for completion /tea CAA-.(S Desired starting dated 2e :7T"
Show sketch of proposed work or furnish 2 copies of separate drawings
a. N
a
w
O
O
O
1
4J
O
a
a�
a�
a
0
U
O
44
U r
. 4
O. Applicant is responsible for contacting the Police Department and CALL BEFORE YOU DIG.
Q,
I agree to furnish to the Town of South Windsor the amount of bond or deposit 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 and will abide by the rules and
regulations for permits as outlined in the Town of South Windsor's (Pavement Cut Regulations.)
Signed_
APPROVED: DATE APPROVED: A�.DATE 3-Zyc
Supt. of Highways Town Engineer
ya:
€' FOR INSPECTOR: ' Date work started Date completed
Sufficient notification received: yes no Type of repair: Perm. Temp.
Unusual conditions encountered
Material slips attached: yes no Dated for Permanent''repair
Signed
Inspector
w .
a l` afr� ,� �. ' r� '� y� , !��` �"~• .fie., j
r
��s UFNI