HomeMy WebLinkAboutStreet Cut Permits Beldon Road c"J
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APP IvATIlI�IL�7l/1C, %.1 W1)/�
Permit Expires
Date of Expiration P
FEE C O D '-=^—EhK. EMIT
Name and address of applicant .J7 '(�/�$ Phone No.
Locatiq of proposed work Oj7 r'vm
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Describe fully nature of permit requested gafAlffl, 4 le U
Insurance on file w' h own s no Date- policy expires
a Name of Insurer
o Approximate time for completion& Desired starting date
Call before you dig ticket Pdo.
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a. Show sketch of proposed work or furnish 2 copies of separate drawings
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OSHA REQUIREMENTS MUST BE FOLLOWED
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a' Applicant is responsible for contacting the Police Depart rent 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 (Pavem nt Cut
Regulations.)
Signed
APPROVED: DATE APP VED: / DATE
Supt. of Highways ' Town Engineer
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