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•` °BOND TOWN OF SOUTH WINDSOR 31'7
Am't Req. tk , PUBLIC WORKS DEPARTMENT Date
TOWN HALL
Am't on File 1540 SULLIVAN AVENUE Permit No.
SOUTH WINDSOR, CT 06074
Dade of Expiration Permit Expires
APPLICATION OR PERMIT ow
FEE $10.00
Name and address of applicant �SrAmm Phone No „G,r yp �_
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Location of proposed work cam.
Describe fully nature of permit requested LxFC#,,j
Insurance on file with Town yes no Date policy expires 3_9-BEj
-Name of Insurer „%p,'
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o Approximate time for completion CIE r1c.)tyjM Desired starting date
Show sketch of proposed work or furnish 2 copies "f separate drawings
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A' Applicant i responsClefor contacting the Police Department and CALL BEFORE YOU DIG.
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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•j924 DATE// - Zh
Supt. of Highways T6wn Engineer
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