HomeMy WebLinkAboutWater Street Cut Permits 424 Clark Stree BOND TOWN OF SOUTH WIMSOR No 4 1013
Arrmtt Req. PUBLIC WORKS DEPARTMENT Date
TOWN HALL
It on File IW SULLIVAN AVENUE Permit No.
SOUTH WINDSOR,.CT 06074
Date of Expiration Permit Expires
-
APPLICATION FOR PERMIT
FEE
Name and Address o licant )-)-'-, C ' a, Phone No.
Sag (eG�S
1) r C ,, e'T' -ter
Location of oposed work . W-;44 C , ) 5 /
i
Describe fully nature of permit equested -- ba
A C
Insurance on ile with Town yes no Date policy expires
c Name of Insurer
O Approximate time for completion Desired starting date
Call before you dig ticket No.
u
a. Show sketch of propose work r furnish Z copies of separate drawings
a � ,
o C1Q IfK
a
•o
N
O W
tJat{ Ck IK t
a+
a
E
O
u
O
y
a.i
O
cd
u
OSHA REQUIR ENTS M ST BE FOLLOWED
a
a
Applicant is responsible for contacting the Police Depanrttent 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- DATE S"/-q+
Supt. of Highways o MP`
neer
FOR INSPECTOR: Date work started Date completed
------ - ---- u ficient note ication received ,,yes no Type of repair: Perm. Temp.
Unusual conditions encountered`'
Material slips attached: yes no Dated for Permanent repair
3A
Signed
Inspector