HomeMy WebLinkAboutNew Conduit Street Cut Permits Intersect soNn TOWN OF SOUTH WIND f`
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F'tt Req. PUBLIC WORKS DEPARTMENT
Date ='r,
on File TOWN HALL
1540 SULLIVAN AVENUE Permit No.
to of Expiration SOUTH WINDSOR, CT 06074
APPLICATIO FOR PERMIT Permit Expires
FEE $10.00
Name and address of applicant
Phone No. r` 4
Location o�rto�sed'w��'1�1'11rk
Describe fully nature of permit requested
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Insurance on file with Town yes no Date
Name of Insurer policy expires
,0 Approximate time for completion
t Desired starting date r-,. 77
Show sketch of proposed work or furnish 2 c
0opies of separate dra
wings
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Applicant is responsible for contacting the Police Department 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 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
APPROVED.pt DATE APPROVED: a
J
Su , of Highways DATE '-i/j Town Engineer
FOR INSPECTOR: ,Date work started
Sufficient notification received: yes no T Date completed
Unusual conditions encountered YPe of repair: Perm. Temp.
Material slips attached: yes no Dated for Permanent repair
Signed
Inspector