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TOWN OF SOUTH WINDSOR 598
Am't Req. PUBLIC WORKS DEPARTMENT
FDate
Am't on File WN HALL
1540 SULOLIVAN AVENUE
Date of Expiration_
SOUTH WINDSOR, CT 06074 Permit No.
APPLICATION FOR PERMIT Permit Expires
FEE $10.00 —
Name and address of applicant � 0
Location of proposed work 4-
Describe fully nature of permit requested
Insurance on file with Town es no Date policy expires
Name of Insurer -�
O Approximate time for completion-4 Desired starting date
u Show sketch of proposed work or furnish 2 copies of separate drawings '
P �
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Applicant is responsible for contacting the Police Department and 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
APPROVED. DATE APPROVED:
DATE —:
Supt, of Highways. Town Engineer
FOR INSPECTOR: Date. work started
Sufficient notification received: Date completed
es no T
Unusual conditions encountered y ype of repair: Perm. Temp.
Material slips attached: yes no Dated for Permanent repair
Signed
Inspector