HomeMy WebLinkAboutInstall Gas Service Street Cut Permit 10 BOND TOWN OF SOUTH WINDSOR
Am't Req. PUBLIC WORKS DEPARTMENT Date
TOWN HALL
Am't on File. IW SULLIVAN AVENUE Permit No.
SOUTH WINDSOR, Cr 06074
�" of Expiration Permit Expires
APPLICATU)eWF-FOR PERMIT
FEE r
Name and address of applicant �a� �. Phone No. -Z9Z _Z 45
—_ - 1+ �
Location of prop sed work ,p� ,�" y, ,�,,
Describe fully nature of permit requested ;�� 1/ ��,�, fin,, y t� Y
Insurance on file with Town es; no Date policy expires
Name of Insurer /q .,;_Q 1 .5
o Approximate time for c mpletion I 7 �-. Desired starting date_ '7- 5, cl,4
to Cali before you dig ticket No. ct 4 Z
U
n. Show sketch of proposed work or furnish 2 copies of separate drawings
ro
o �
C
o
"y
CL
it
y
a�
U 3�5 rT
0
V
OSHA REQUIREMENTS MUST BE FOLLOWED
a.
4 Applicant is responsible for contacting the Police Department end CALL BEFORE YOU DIG.
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 77 ;1? L k
APPROVED: DATE APPROVED: DATE 7//
Supt. of Highways o is eer
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
V (-v I Signed
suector