HomeMy WebLinkAboutWater Street Cut Permits 382 Beelzebub R BOND TOWN OF SOUTH wMSOR
Am It Req. PE IC WORKS DEPARTMENT Date
TOWN HALL
It on File 1540 SULLIVAN AVENUE
SOUTH WIND60R,CT 06074 Permit No. G^a
Date of Expiration Permit.Expires
APPLICATION JPR PERMIT_
FEE
Name and address of applicant K
hone No �( - ( �
Location of proposed work
Desc ibe fully nature of permit requested
l7� e2
Insurance on file with Town yes no Date policy expires
Name of Insurer 4,,r-fi3e-
.°c. Approximate time for completion Desired starting date
Call before you dig ticket No. �
a. Show sketch of proposed work or furnish Z copies of separate drawings
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as• _ - rat:- /�7/ i7� �'
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OSHA REQUIREMENTS MUST BE FOLLOWED
a
4 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 APPRO D. ATE10`
Supt. o Highways Town ngineer
FOR INSPECTOR: Date work started Date completed
Sufficient ;otifica,tion received: yes
no �ype of repairs P ri smp..
-- — I�nusual conic itions encountered __
Material slips attached: yes no Dated for Permanent repair
Signed
Inspector