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BOND TOWN OF SOUTH WINDSOR 433
Am It Req. PUBLIC WORKS DEPARTMENT Date
Qm' TOWN HALL
t on File 1540 SULLIVAN AVENUE
Permit No.
Date of Expiration
SOUTH WINDSOR, CT 06074
APPLICATION FOR PERMIT Permit Expires
FEE $10.00
Name and address of applicant ;. Phone No
Location of proposed work
Describe fully nature of permit requested
Insurance on file with Town yes no Date policy expires
Name of Insurer
o Approximate time for completion Desired starting date
Show sketch of proposed work or furnish 2 copies of separate drawings
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CApplicant 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.)
Signed
APPROVED. DATE APPROVED: f j DATE
Supt. of Highways ,
. Town En `sneer
FOR INSPECTOR: Date. work started
Date completed.
Sufficient notification received: yes no Type of repair: Perm. Temp.
Unusual conditions encountered
Material slips attached: yes no Dated for Permanent repair
Signed
Inspector