HomeMy WebLinkAboutStreet Cut Permits Buckland Road BOND TOWN OF SOUTH WINDSOR 595
Am't Req. PUBLIC WORKS DEPARTMENT
TOWN HALL Date
Am't on File 1540 SULLIVAN AVENUE
Date of Expiration
SOUTH WINDSOR, CT 06074 Permit No.
APPLICATION FOR PERMIT Permit Expires
FEE $10.00 - -Pi C` 4
Name and address of applicant 5j4c cjc. - wv►.
Phone No.
Location of proposed work
Describe fully nat of permit re ested _
Insurance on file with Town yes no Date policy expires
Name of Insurer
o Approximate time for completion Desired starting date
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. Show sketch of proposed work or furnish 2 copies a of separate drawings
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�a 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: !, y7
Supt. of Highways DATE_
�;;- Town Engineer
. FOR INSPECTOR: Date work start d
Sufficient notification received: yes no T Date completed
Unusual conditions encountered Type of repair: Perm. Temp.
Material slips attached: yes no Dated for Permanent repair
Signed
Inspector