HomeMy WebLinkAboutSewer Installation Street Cut Permits Da (3) /LLS AND TOWN OF SOUTH W N SOR
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9• PUBLIC WORKS DEPARTMENT Date
t on 'i1e TOWN HALL
' 1540 SULLIVAIV AVENUE
Permit No.
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;Date of Earpira on.,
SOUTH WINDSOR, CT 06074
APPLICAT O _ O PERMIT Permit Expires
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FEE $10:00 �.
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Name-and address of applicant T a
Phone No. 4-21
Location of proposed work
Deseri a folly nature of permit requested
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-nsurance on'file with Town a no Date poiicy expires
Name of Insurer
Approximate time, for completion
Ca11 before you d t ket-•T1o. %� Desired sta. tj,ng date /�rS n {, /a
a ` Show sketch of proposed work or furnish 2 copies of separate drawings
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Applicant is responsible for;contacting the Police Department and CALL BEFORE YOU DIG.
I agree to furnish to the Town of South Windsor the amount of bond or deposit required and to
reimburse the Town of South Windsor for any expenses incurred by the Town for maintenance or repair
work in connection with this permit and that, I am familiar with and will abide by the; rules and
r' regulations'for on
as outlined in the.Town of South Windsor's (Pavement Cut Regulations.)
Signed
APPROVED: DATE APPROVED•
DAB E zS k
Supt. of Highways
o n E�ri veer
FOR INSPECTOR: Date'Work ;started Date completed
ufficient notification rec-eived: yµes T no w ype_of_r-epa r:- _Perm Te
Imxsurxlollflt3is encouere
Material slips a.ttach;ed: yes no Dated for.Permanent repair
"$peetor,