HomeMy WebLinkAboutDriveway Street Cut Permits Clark Street IYVMTW vzwk
BOND, 0980
Am Req. PUBIC WQRl€$ DMPAI�7�rfSNT Tate
TOWN HALL
't on File 1540 SULLIVAN AVENUE Permit No.
SOUTH Wl DSOR,'CT 06074 z
Dat.o of Expiration Permit Expires
APPLICATION FOR P RMIT° ----=
FEE 'S/0 0 O ry '
F' Name and address of a lican "
PP Phone Wd%
ocation of proposed work
escribe fully nature of permit requested (�
,.
Insurance on ile with Town a no ate policy expire$
Name of Insurer
€ 0 Approximate time for completionj
Desired start ng: to
Call before you dig ticket. No.
Show sketch- ' proposed work or furnish 2 copies of sepaiate drawings
p t .
� �• is �`
OSHA REQUIREMENTS MUST BE FOLLOWED ` '"
Applicant is respons6k for contacting the Polio Department and CALL BEFORE.YOU DIG.
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I agree to f n*b to the Town of South;Windsor the amount. of bond or deposit required and-�o,
reimburse the Toga of South Windsor for any expenses inanrred by the Tolin for maintenance or.repair;
work in connection with this permitr and that I am fam0iar With and will abide by the rules end ;
regulations for permits as outlined in'the Town of South W s IPavemient Regulations.),
F
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Signed
APPROVED: DATE APPROVE DATE
Supt. o ghways o ear
ted
FOR 4
c entPno i-Ocationreceive dR: Date work$tayes �-`o a of repair:tpe teds --
yPPerm. Temp.
Unusual conditions encountered
--------Material--slips-attached:-yes" -- no ---Dated for erm-anent.repair - - - - -- —"
Signed
e eetor