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Am't Req. ;K;''�i,� PUBLIC WORKS DEPARTMENT Date ,�: — -
TOWN HALL
96
Am't on File 1540 SULLIVAN AVENUE Permit No.
' SOUTH WINDSOR, CT 06074
IDate of Expiration Permit Expires
APPLICATION FOR PERMIT
FEE $10.00
Name and address o a t L /_fib C '. Phone No.
Location of proposed work
Describe fully nature of permit requested
Insurance on file with Town dyes.' no Date policy expires
Name of Insurer s
O Approximate time for completion Lj- Desired starting date
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Show sketch of proposed work or furnish 2 copies of separate drawings
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Ra' Applicant is responsible for 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: /
�► ' ' 'ft' ATE
Supt. of Highways T6wn Enginee�
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