HomeMy WebLinkAboutGas Main Street Cut Permits Beldon Road AVUlIl W1IVLJVlt� 1.1 UUU/4
Date of Expiration Permit Expires
APPLICATION FOR PERMIT
FEE $10.00
Name and address of applicant C o � Phone No �� l
Location of proposed work
Describe fully nature.of permit requested 7_A.c,t�7.
Insurance on file with Town f yes..,.--,,'no Date policy expires
Name of Insurer E. -7
o Approximate time for completion { G-1 V;, . Desired starting date
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Show sketch of proposed work or furnish 2 copies of separate drawings
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134 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: � � DATE
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Supt. of Highways �/,:-�Town Engineer
. FOR INSPECTOR: Date work started Date comnIntecl