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BOND TOWN OF SOUTH VAMSOR
AmIt Req._ PUBLIC WORKS DEPARTMENT Date
TOWN HALL
It on File- - 1540 SULLIVAN AVENUE '-. -Permit No. �
SOUTH WINDSOk Cr 06074
Date of Expiration Permit Expires
APPLICATION R PERMIT
FEE
Name and address of ap li ant -Cl /ZS, /�_ "
�r r; �Ct Phone No.
Location O&Oroposed work
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Describe fully nature of peirmit requested Aj..
Insurance on file with Town es no ate policy expires :,:K t -
Name of Insurer
0 Approximate time for completion Desired starting date
Call before you dig ticket Pdo.
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Show sketch of proposed work or furnish 2 copies of separate drawings
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OSHA REQUIREMENTS MUST BE FOLLOWED
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a Applicant is responsible for contacting the Police Depamnent 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.)'
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Signed
APPROVED: DATE APPROVED: /� ,?� DATE 9'I�
Supt. of Highways )7A-72 Town Engineer
FOR INSPECTOR: Date work started Date com leted
�. P
u iciest tzofi sca ion-received:- - yes - no - ype of"-"repair: Perm.-- Temp.
Unusual conditions encountered
_Material slips attached: yes no Dated for - ermarent repair'-
Signed
Inspector = `
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