HomeMy WebLinkAboutPatch ditch made by utility Street Cut P . P.IbND TOWN OF
OUTI3 WINDSOR
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,trint9• PUBLIC WORKS DEPARTMENT
TOWN HAIL Date
't .on File, 1540 SULLIVAN AVENUE
Dane of Expiratio .. ,
SOUTH WINDSOR, CT 06074 Permit No.
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Permit Expires
APPLICAT N F PERMIT
FEE sio.Q0
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Name and address of applicant
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Location of proposed work ,} r
Describe fully nature of permit request
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Insurance on file;With7own yes no Date olic eName of InsurerP y xpires
Approximate timr completion
K Desired startiz}g date
ca Call before you dig ticcet Ldo;
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4. _ - F
a Shover sketch of proposed work or fu s_ 2 copies f separate drawings
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Applicant is responsible for contacting the Polio 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 ar�c�
regulations for
Permits as outlined in the Town of South Windsor's (Pavement Cut Regulations.)
Signed s.
APPROVED: DATE APPRO ED-
Supt, of Highways TE DA 74 .
,s
o n E i eer
FOR INSPECTOR-
Date
_ , work started Date completed
of icient es no notification received:
y e_of repair: l'e.rm hemp:-
Unus-ual c�®editions-encourrered-- _._ �. �� __
Material slips attached: yes no Dated for Permanent repair
Signed
- _ spectoi�