HomeMy WebLinkAboutRepair water line Street Cut Permits 203 BOND TOWN OE SOUTH WINI SOR 09,8�
Am It Req. PUBLIC WORKS DISPAVIV9W
TOWN HALL Rate
It on Filt I _0 SV IVAN_AVENUE Permit No.
SOUTH WINDSOR,Cr o6o74
� Date of Expiration Permit Expires /
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APPLICATION ICATION FOO$. PERMIT --�-
Name an# address f ap licantboll h'1one No.
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1157,W1
Location of proposed work '.
Desc be ull nature of permit requested r
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Insurance on i e .with Town es no Date policy expires
c Name of Insurer �.
o Approximate time for comp alionDesired starting to
Call before you dig ticket t1o. (�g
Show sketch of-proposed work or. furnish 2 copies'of sepa"rate drawings
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OSHA REQUIREMENTS MUST BE FOLLOWED
4 Applicant is responsible foe contacting the Police Depamnent and CALL BEFORE YOU DIG.
I agree to famish 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 re-
work in connection with this permit and that I am famim with and will abide by the
regulations for permits as outlined in the Town of South Windsor's IPava lient:Cut Regulations .
Signed f
APPROVED. DATE APPROVED: DATE
Supt. of Highways eer
. " FOR INSPI:�CTOR: Date o_ w rk started Date, oornpleted
u xcient notification received: yes no Type of repair: Perm. Temp. . .
Unusual conditions encountered
-----Material slips-.attached:- yes• no - Dated-for- ermanent
Signed - .
_ ' ��ector