HomeMy WebLinkAboutRepair broken water main Street Cut Perm (5) ' $4
$02 TOWN OF SOUTH WINDSOR
Am't Req. PUBLIC WORKS'DEPARTMENT Date
} ' TOWN HALL Permit No,
�t on `ile 1540 SULLIVAN AVENUE
& SOUTH WINDSOR,CT 06074
k - date'of expiration Permit Expires
APPLICA►TION FOR PERMIT
FEE $10.00 �� '
Name and address of applicant G 1.._J c,. .� Co: Phone No. U Z? --z 77 .`(
'cation of proposed work
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Describe u ly nature of permit requested tf r� cr kl 1y
1r� - C ilVl r i -'I
Insurance on file-with Towne e.s no Date policy expires
Name of Insurer
Appr9xiniate, time.for coix pletion Desired starting date
o
' Call before you d ` ' cct No. r
Show sketch of proposed work or furnish 2 copies of separate drawings
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12+
' 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 1 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,;- ATE
Supt. of Highways �'f'o" Enf E r
FOR INSPECTOR: Date work started Date completed
Su i ent et f eat one ec ei-0— y es- - no T-ype--of repair:Perm:- f giiip..-
Uhus,ual conditions encountered .
Material slips ,attached: yes no_, Dated for Permanent repair
Si gned
In"spector _