HomeMy WebLinkAboutTelephone Street Cut Permits 400 Chapel (2) o TOWN OF So'PT INDSOR y 6
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Arn't Req.' PUBLIC WORK,4� PARTWNT Date
- TOWN-HALL
't on:FilE 1540 SULLIVAN AVENUE Permit No.
SOUTH WINDSOR, CT 06074
Date''of Expiration
APPLICATION FOR PERMIT Permit Expire
FEE $10.00 -
Name and address of applicant 7N(, Phone No.
. Location of proposed work Chu e/ R.1
o c , Su ?8
Describe`fully nature of permit requested
J Insurance on file with Town yes no Date policy expires "
Name of Insurer
Ft s; 4 i Approximate time f completion Desired sta:rtin date�'' 3 ;.
Call before you dic �r et t1o. 90/y/ v
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.
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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 ,� �,� li,. -`
APPROVED: DATE APPROVED: / �
1� DATE �f- So
Supt. of Hi gliways To*n Engineer
FOR INSPECTOR: Date work started Date completed
^�;.•c:rya^+vv�'r•W- .. ` -- —
-eparr:—Penns:----Terms:_____
Unt ual conditions encountered
Material slips attached: yes no ated for Permanent repair
Sighed
_ Inspe� ir`