HomeMy WebLinkAboutRepair gas main Street Cut Permits Dawn y i
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t" e :r 150;SI7LLI`VAN1VETUE Permit No.
K` (?T1T I WINDS
CT 06074 S
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5 --- -�,_ Permit.Expires
APPLICATIONI .FOR PERMIT
FEE $10.00. -
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Name and address of applicant 1,441TF E 6-14S Phone No
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Location of proposed work ,•,
D'e gibe fully nature of,permit requested
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Insurance on file with Town no Date'policy expires
Name,of Insurer r
o Approximate tirrLe for completion Desired starting date
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Call. 'before you digs picket No. b7y6/y�g ay.
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a Show sketch of proposed,work or furnish 2 copies of separa a 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
regulations for permits as outlined in the Town of South Windsor's (Pavement Cut Regulations.)
sr Signed C . Zoe,
APPROVED: DATE APPROVED: DATE
.x Supt of Highways ' Z;7�own Engineer
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"Ot1SPECTOR: Date wor
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Date completed
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^ 6ieut not�ftcation re.celv,;ed: yes no Type of repair: Perm. Temp.
ttn�is a1 Condition's encourite a .: ,
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= �Ecrl ,slips" attached: yes no..: - m ateJoe Peranent repair
,^ $ Signed
i k _ _ apector.