HomeMy WebLinkAboutRepair water main leak Street Cut Permit (3) $oND TO IY OF SOUTH. WINDSOR ; dam$
Am Req�'_ PUBLIC WORKS` DEPARTMENT
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TOWN.HAIL.
t �i4te
't;Fon"File 1540'SUIJUVAN AVENUE Fermciit No.
SOUTH WINDSOR,CT 06074 t `
Date of Expir*tioa
I ermnit Expires
"PLICATIO " PERMIT
FEE
Name an addres of ap licant tr Pb one No.
r � t .
Location. o proposed work
Describe fully nature of permit requested
Insurance on file with Town es no ate policy expires
Name of Insurer — �---
o` Approximate time .for completion(} Desired starting' to
Cull before you dig ticket M- ( ! 17
a. Show sketch of proposed work r furnish 2 opies 'of sepairate drawings
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SIP It-At er l Ott i
MI
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F OSHA REQUIREMENTS MUST BE FOLLOWED
a.
Applicant is respons6le for contacting the Police Deparunenr and CALL BEFORE YOU DIG.
I agree to furnish to the Town of South Windsor the amount of bond for deposit
epos�i required and t4:,
refthburse the Town of South .Windsor for any expenses incurred by the Town for maintenance;'ri repair
work in connection with this permit and that I am famEiar with and :dill abide by the : ' acid '
regulations for permits as oud fined in the Town of South Windsor's (Pavtemt Cut Regniat o ..►
Signed. ( �i h
:-APPROVED: _ DATE APPROV ,D; /,DATA + ^Z `3 `
Supt.-o Highways
wa s �L Town Engineer
rOR INSPECTOR: Date work started Da l► p1osT�eti _____
_�� _ ---buff
iciesnt note s ation received: yes noType of repairs Perim. emp.
,0ausual conditions encountered
slisp y no Dated for m er "anent repair --- ---- --
attached:'-- es
Signed
- pecto�t ;