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BOND TOWN OF SOUTH WMSOR
Arn't Req._ PUBLIC WORKS DEPARTMMT Date
TOWN HALL
It on File 1540 SUUJVAN AVENUE Permit No.'"7.- C)ZZ
' SOUTH WINIMR,CT 06074
Date of Expiration Permit Expires
APPLICATION FOR PERMIT
FEE
Name and address of applicant /�J ,7" / Phone No, Z �
Location of proposed work d'
Describe fully nature of permit requested
Insurance on file w' h Town ngL ate.policy expires -
Name of Insurer
oApproximate time or corrmplet on W Desired starting to / , r
Call,before you dig ticket 116.
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Show sketch of proposed work or furnish 2 copies of separate drawings
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OSHA REQUIREMENTS MUST BE FOLLOWED
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4 Applicant is responsible for contacting the Police Deort"Ut 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 ruleb and
regulations for permits as outlined in the Town of South Windsor's (Pavement Cut Regulations.):
Signed
APPROVED: DATE AP' PR4 VI
DATE v,1 `
Supt. of Highways Tows. ngeer
FOR INSPECTOR: Date work started Date completed
u iciest not ication received:: yes no ype of'rep`�►is._ Pert?n. e1�0np.^�
Unusual conditions' encountered
Material slips attached: y`ps no . Dated for _:err�caster�t repair
Sr $ned
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