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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 FOR PERMIT
FEE $10.00
Name and address of applicant tL4 /j�(� I���C'LN T Phone No
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Location of pro45osed work (4 C/q Ld1A tZeL ,aA7
Describe fully nature of permit requestedyl�/rU1u
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Insurance on file with Town es no Date policy expires
Name of Insurer Lulls
o Approximate time for completion C) yA�Desired starting date a,t
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Show sketch of proposed work or furnish 2 copies of separate drawings
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a' 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 Re lations.)
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Sig ne&
APPROVED: DATE APPROVED: 1`f _-. DATE
Supt. of Highways 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