HomeMy WebLinkAboutStorm Street Cut Permits Farnham, Meryl, N2. 1033
BOND TOWN OF SOUTH WINDSOR
Am't Req. PUBLIC WORKS DEPARTMENT Date
TOWN HALL
It on File 1540 SULLIVAN AVENUE Permit No.
SOUTH.WINDSOR,CT 06074
ate of Expiration Permit Expires
APPLICATIO FOR PERMIT
FEE
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Name and address of applicant P,.,.,�4C cctZk n.,c, , do , 09 + r Phone No
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Location of proposed work s�
Describe fully nature o� permit requested
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PAVir46, A,40 P4s411-41.1.1
Insurance on file with Town es no Date policy expires
Name of Insurer Qfvw. 4- ^s 1 7,
o Approximate time for completion (jo O Desired starting date
Call before you dig ticket No.
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a. Show sketch of proposed work or furnish 2 copies of separate drawings
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OSHA REQUIREMENTS MUST BE FOLLOWED
04 a.
d 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 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: DATE
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-Suet. of Highways o eer
FOR INSPECTOR: Date work started Date completed
u ficient noti ication received: yes no Type of repair: Perm. Temp.
Unusual conditions encountered
Material slips attached: yes no Dated for 15,erGanent repair
Signed
Inspector