HomeMy WebLinkAboutReplace electric cable Street Cut Permit rG,
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Am"it Req�. PU�IIC Wf.��iKS DEPAR17rtIiN'r � ,
+ ,FY 4.
4t on.File 1540=SULLIVAN ,l iMJ9
Rermit No.
SOUTH WiN R._Cr 4
<Date oi: aprrattott P Expires
' APPLICATION O� PERMIT 3
FEE"`
Name and address of applicant4, / PhomeNo.
Location of propose- work r� 111=- "- -- -
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Descri a fully nature of permit requested
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4 Insurance on.file with Town yes no aEe policy exp�rea
Name of Insurer
Approximate time for completion esired starting trees.
fall before you dig ticket Mo. S � t :
Show" sketch of proposed work or furnish 2 copies of separate.drawings
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f E'enr . Lou RA-M
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P"
r OSHA MUIRT MENTS MUST BE FOLLOWS
" Apolkint is tespoosibit for contacting the Police Depantnenr and CALL BIF. ORE YOU DIG. <
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fi I agree to furnish to the:Tows of South Windsor the aft. of boed Ior deposit 't+eQuil and to
"Reimburse,the Tcnva of South Windsor for any ezpenaes incpcted by the 'oviin foi� Yaaintei�ance or emir
work in connoct m with this pernit and that I am familiar-with stud *M abide by the rules and
' Lions fcNr Y f. egula perynita as .c►udiined in :the Town of South Windsor's• (Pavement (;at'li lations l
Signed
' APPROVED: DATE APPRpYEDz DAT1
Supt. of HighwaysG Town'Eng+ineer
i Fi�,ft-INSPECTgR: Date work-atartgd. �_:._.� Dat.e:_completed - - -- --•:.�
u ficieni notification received: yes no Type—of of r,ep�ir: Perm. a jr�.
Unusual condiitoas;encountered
Material slips attaFhed: yes no Dated for P ermanent re'p;tir
Signed `
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