HomeMy WebLinkAboutStreet Cut Permits Clark Street pump sta r.
BOND TOWN OF SOUTH WINDSOR '
Am't Req.
_ rt PUBLIC WORKS DEPARTMENT F
t e
't off, File 1540 SULLIVAN AVENUE
TOWN HALL
Date of Expiration SOUTH. WINDSOR, CT 06074 Permit No.
APPLICATION FOR PERMIT Permit Expires
Name and address of applicant
Phone No. _.•..< " ..;_
Location of proposed work s
Describe fully nature of permit requested.
r.
Insurance on file with Town yes' no D
� Name of Insurer ate policy expires
•o Approximate time for completion
u Call before you dig ticket No. Desired starting to /N/Nz�
Show sketch of proposed osed work or furnish 2 copies of separate dravc+ings
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QApplicant is responsible for contac 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: DATE APPROVED:
Supt. of Highways DATE
T �Ce r
`g• T
FOR INSPtCTOR: Date work started
Sufficient notification received: yes Date completed
Ltnusual conditions encountered no
-Type of repair: Perm. ---`
p.
Material slips attached: yes' no Dated for Permanent repair
Signed
Ins ector