HomeMy WebLinkAboutReplace leaking Street Cut Permit 2 Aher "BOND TOWN OF SOUTH WMSOR
Am It Req._ PUBLIC WORKS DEPARTUMT [Date't on File - TOWN HALL,1540 SULLIVAN AVENUE ermit M.
Date of Expiration
SOUTH WMWR,CT 06074 -----
.APPLICATION R PERMIT Permit Expires
FEE _ IV
Name and ddress of ap lica t
Phoae Noy
Location o proposed work ,
Describe fully nature�of permit requested
Insurance on file with Town yes no ate olic
Name of Insurer P Y expires
0 Approximate time for completion Desired startin
to Call before you dig ticket No. g date
u
Show sketch of proposed work or furnish 2 copies of separate drawings
a
�.
0
0
6
e
Qrt
o
8'
OSHA REQUIREMENTS MUST BE FOLLOWED ~
a
Q Applicant is responsible for contacting the Police Department and:CAU 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 Town for
work in connection with ,this permit,and that I am familiar with and will abide maintenance or repair
regulations for permits as outlined ifr the Town of South Windsor's (Pavement Cut a the miles and
Regulations.)
Signed11
.. l
APPROVED: DATE APPROVED: A%b DATE
Supt. of Highways` Tows Engineer
FOR INSPECTOR: Date work started
Date completed
u icient noti ication received: yes no
Unusual conditions encountered ype of repair: Perm. Temp.
Material slips attached: yes no Dated for Permanent repair
Signed
spector