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BOND TOWN OF SOUTH WINDSOR
Am't Req. PUBLIC WORKS DEPARTMENT Date
TOWN HALL
Am't on File 1540 SULLIVAN AVENUE Permit No.
SOUTH WINDSOR, CT 06074'-_
Date of Expiration Permit Expires
APPLICATION ,: 'D 'P RMIT
FEE $10.00
Name and address of, a 1' ant 5' 3 f
PP �v r t3 ��� Phone No. �> �l
Location of proposed work ! f' •"�;
Describe fully nature of permit /requested iI{
Insurance on file with Town yes no Date policy expires
Name of Insurer
Approximate time for completion 1 GyC'Ct� Desired starting date -,2
U Show sketch of proposed work or furnish 2 copies---bf separate-drawings
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O" contacting the Police Department and CALL BEFORE YOU DIG.
Applicant is responsible fof'
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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, y �� y
APPROVED: DATE APPROVED f„ ATE 2
Supt. of Highways Town Engineer
FOR INSPECTOR: Date work started Date completed
VO _-__-___Sufficient notification received:-_ yes- no Type ofrepair: Perm. -Temp. -
Unusual conditions encountered
Material slips attached: yes no Dated for Permanent repair
Signed
Inspector