HomeMy WebLinkAboutReplace valve Street Cut Permits 111 Cad k`
BOND TOWN OF SOUTH NVMSOR
AmIt Req. PUBLIC WORKS DEPART?MM Date
TOWN HALL
It on File - 1540 SULLIVAN AVENUE Permit No. (�
SOUTH WINDSOR,Cr 06074
Date of Expiration APPLICATION PERMIT
Permit Expires
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FEE
Name and address of appl'cant Phone No
t1t
,S 4)T�WTJ ,
Location -oT propoi3ed work
Describe fully nature ofpermit requested
Insurance on file with Town es no Date policy expires
Name of Insurer
o Approximate time for completion Desired starting date ✓
td Call before you dig ticket No. .0
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Show sketch of proposed work or furnish Z copies of separate drawings
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0
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0
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OSHA REQUIREMENTS MUST BE FOLLOWED
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Q Applicant is responsible for contacting the Police Departamat 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 To i n 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 I 7(
APPROVED: DATE APPROVED: DATE
Supt df-Highways Town Engineer
FOR INSPECTOR: Date work started Date-completed
u ficient noti ication received: yes no Type of repair: Perm. Temp_ .
Unusual conditions encountered
- -- -.Material slips attached: yes no Dated for Permanent repair
Signed
inspector