HomeMy WebLinkAboutGas Main Street Cut Permits Dart Hill Ro (5) BOND TOWN OF SOUTH WINDSOR N5 . 714
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Am't Req. PUBLIC WORKS DEPARTMENT Date
TOWN HALL
Am't on FilE, 1540 SULLIVAN AVENUE Permit No.
SOUTH WINDSOR, CT 06074
Date of Expiration Permit Expires
APPLICATION FOB, PERMIT
FEE
Name and address of applicant—t6v. Phone No.
Location of proposed work
Describe fully natifre of permit requested. ./ , �r--�
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Insurance on file with Town s no Date policy expires
Name of Insurer
o Approximate time for completion- Desired starting to
Call before you dig ticket No.
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Show sketch of proposed work or furnish 2 copies of separate dings
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Applicant is responsible for contacting the Police Departmen�, CALL BEFORE YOU
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 connections with this permit and that I, am familiar with and will abi4e-,,.by 'the riles and
regulations for permits as outlined in the Town of South Windsor's (Pavement C t"°Regalations.) ,
Signed
APPROVED. DATE APPROVED: , DATE
Supt. of Highways Tl�� Town Engineer
�+! FOR` RSPECTOR: Date work. started_ Dat e completed.
Sufficient noti ication received: ye' s no Type of repair: Perm.. Temp..
Unusual conditions encountered
Material slips attached: yes no Dated for Permanent repair
Signed.
Inspedtor