HomeMy WebLinkAboutDomestic/Fire Protection Street Cut Perm BOND TOWN OF SOUTH WINDSOR
Am't Req. PUBLIC WORKS DEPARTMENT
Date
m'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 o applicant ( /
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J �1 Phone No. _
Location of proposed work tZ T '){ C3 F
Describe fully nature of permit reques
Insurance on file with Town yes? no Date policy expires I }
Name of Insurer ;
o Approximate time for completion L_, ;t Desired starting date
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Show sketch of proposed work or furnish 2 copies of separate drawings
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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;..f. f� : r
APPROVED: DATE APPROVED: DATE ,'
Supt, of Highways ~ )P#r Town Engineer � �
FOR INSPECTOR: Date work started Date completed
Sufficient notification received: yes no Type of repair: Perm. Temp.
Unusual conditions encountered
Material slips attached: yes no Dated for Permanent repair
Signed
Inspector