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APPLICATION FOR DRAIN IAYER PERMIT
TOWN OF SOUTH WINDSOR
PUBLIC WORKS DEPARTMENT
- TOWN HALL _
1540 SULLIVAN AVENUE
SOUTH WINDSOR, CT
FEE $60.00 nn
LMUM Of Proposed work: —(i wr e r _'Ga ' tut:#
Street No. Strae(Name
Premises owned by:_L�cvv�_
-Name oftirm` iCo /S Qw (' • ,l- 6 QvI Phone: �LR- kS Zd'
Address.of Firm:_ /38
TYPEOFWORK:
Drain Repair House Drain -
Mai G • Lay lataraffor Commerdal/Industrial
of aces -
connection will be made vdth
8ftng Water Supply: Public Water ✓- Well
PF)POSadStartDate_41110S Estimateddimeforcomplepon 2weeb .
ALL WORK.TO BE IN ACCORDANCE WITH TOWN OF SOUTH WINDSOR STANDARDS,
ALL OSHA REQUTAEMENtS AND CONDITIONS ATTACHED TO THE PERMIT
PemnRis to be Issued to I the holder of Drain
Layer's Uoense No. 7D.2 Onlyhoklers ofP-I, P-7 or WA nowses - -
will be Issued a Permit PERMIT WILL EXPIRE THIRTY (30) DAYS AFTER
DATE OF ISSUANCE. The undersigned Drain Layer hereby agrees to all the terms '-
'and wrldrd"set forth In the permit and attached thereto. Applicant has received
Town Steet Excavation Permit No. and/or ConnDOT Permit No.
CBYD No. a90ya lO D- S$8
Signed: Print Name: 4f,t.kra�f L ,�Nee�
Ucensetl rain Layer
Date: S 2
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