HomeMy WebLinkAboutRepair gas leak Street Cut Permits Dogwo BOND TOWN OF SOUTH WIND SOR N° �02
Ain't Req. PUBLIC WORKS DEPARTMMT Date
TOWN HALL
't on File 1540 SULLIVAN AVENUE Permit No.
SOUTH WINDSOR, CT 06074
Date of Expiration Permit Expires
APPLICATION� FOR PERMIT
t
FEE �v'.9
Name and address of applicant An
�r(, & „ „ (,.,, ,� Phone No. q Location of proposed work
De—es^crib e fully nature of permit requested 77am � A
�\ A oat
.eN.
Insurance on file with Town es no Date policy expires
c Name of Insurer AQ QM
o Approximate time for c- orhpl7etion� Desired-starting dater
Call before you dig ticket I;o. ti 7 y
a. Show sketch of proposed work or furnish 2 copies of separate drawings
a
o �
0 7.
t+
O
a
a7c>o�w0c.31a, �C"%
U
O __.
d
OSHA REQUIREMENTS MUST BE FOLLOWED
a
4 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.a> expenses incurred by the Town for maintenance or repair
work in connection with this permit and that �I a #amiliw with and will abide by the Hiles and
regulations for permits as outlined in the Town of South Windsor's (Pavement Cut Regulations.)
Signed
APPROVED: DATE APPROVED: DATE :2L�y
Supt. of Highways p�:� Town Engineer
FOR INSPECTOR: Date work started Date completed
Sufficient noti ication received: yes no ype of repair: Perrin. Temp.
Unusual conditions encountered
Material slips attached: yes no Dated for Permanent repair
Signed
# Inspector