HomeMy WebLinkAboutTelephone Street Cut Permits Ellington R �� 1 �'.,s ".r ♦ z a�s 7 - .' �"i�y',-�_ -g� � xs^t'=;n � :e:"N C'Y'rX 'er:r. T a r
'BOND TOWN OF Sd1j 14 WINDSblt
Am'tq. _PUBLIC WORKS DEPARTMENT
Date
TOWN HALL
m't on File 1540 SULLIVAN AVENUE Permit No.
t , SOUTH WINDSOR, CT 06074
Date of Expiration. Permit Expires_
APPI.ICA FOR P RMIT
`FEE $10.00
Name and address of applicant w r'I' . ��U�f°' Phone No.
Location of proposed work a¢ i,,,
escribe fully nature°of permit requestedCa>✓t-� 't, vcS
� aCe'�.•. � ' fv Xi'sr D�stS �•D
F' Insurance on file with Town yes no Date policy expires
Narne of Insurer '
A proximate time, f r completion 30
f 9 Pp P D S Desired s�art�r g date .f d
Call. before you di§ �t3 cket rdo g 13 Dl�p
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Show sketch of proposed work or furnish 2 copies of separate drawings
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+ Applicant is responsible for contacting the Police Department atd 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.)
ligned
APPROVED. DATE APPROVED_ : DATE
Supt. of Highways o neer I
FOR INSPECTOR:. Date work started `- .Date completed
Sufficient notification r-ice ved-.' -yes , = no Type-of-repair Perm eZ mps
Unusual conditions encountered
Material slips attached:- yes. no Dated' for Permanent repair
-- -- - Signed-
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