HomeMy WebLinkAboutInstall box at gas main Street Cut Permi BOND TOWN OF SOUTIR WINDSOR ,
Am't Req. PUBLIC WORKS DSPARTMENT Date
TOWN HALL
it on File 1540 SULLIVAN AVENUE Permit No.
SOUTH WINDSOR, CT 06074
Dato of ;Expiration,,
' Expires
APPLICATION FOR PERMIT Permit
FEE $10.00
Name and address of a licapt
PP S. Phone No. S"2-
Location of proposed work ,:21z
eseribe fully nature of permit requested f`r'
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Insurance on file with Town yes no Date policy expires;
. Name of Insurer 4 ,
1 Approximate time„fo?r,completion f j ti Desired start"og date ' �7o
f Call-before you di c picket No. n°fit:
5 " Show sketch of proposed work or furnish 2 copies of separate drawings
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�P' 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 inonneatiQn with-this permit sand that I am familiar with and will. abide by the rules and
regulations for permits as outhn d/"in the Town of South Windsor's (Pavement Cut Regulations.)
Signed - r�
.APPROVED. DATE APPROVED; TE 0 .
Supt. of Highways "Town'Engneer
FOR INSPECTOR: Dati work started Datp completed
uffcient' notification received: es no T P
— - - - Y _ � --- ype of repair_Per emmm _ --
Uit1tisu `conditions encounteec� -
Material slips attached: yes no Dated for Permanent repair
Signed
R
Inspector• .