HomeMy WebLinkAboutGas Main Street Cut Permits 7 Dart Hill BOND TOWN OF SOUTH WIMSOR N° Jos o
Am't Req. PUBLIC WORKS DEPARTMENT Date
TOWN HALL
It on File 1540 SULLIVAN AVENUE Permit No.
SOUTH WIIVDSOR, CT 06074
Date of Expiration Permit Expires'
APPLICATION FOR PERMIT
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Name and address of applicant Y�n� a ,;-, Phone No. 9] LI5
Location of proposed work_ ^7 ZR N
Describe fully nature of permit requested_��
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Insurance on file with Town Cji�-9) no Date policy expires
Name of Insurer�,d o ,
.°c. Approximate time for mpletion � W � Desired start m date
Call before you dig ticket 14o. g
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aShow sketch of proposed work or furnish 2 copies of separate drawings
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a. OSHA REQUIREMENTS MUST BE FOLLOWED It-aj
p' Applicant is responsible for contacting the Police Department and CALL BEFORE YOU DIG.
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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
regulations for permits as outlined in the Town of South Windsor's (Pavement Cut Regulations.)
Signed
APPROVED: DATE APPROVED:--,ggd,6 DATE Gj U7
Supt. of Highways J�L 2a Town Engineer
FOR INSPECTOR: Date work started Date completed
u ficient notification received: yes no Type of repair: Perm. Temp.
Unusual conditions encountered
Material slips attached: yes no Dated for Permanent repair
Signed
Inspector