HomeMy WebLinkAboutWater Street Cut Permits 400 Governors H `RT
" =x ` Qly� TOWN Of S`O WfiD01 b
t 't Req. PU$LIC WOKS$lDPARTMM'T Iit
s 't oq`File 1540,.SULLIVAN AVENUE Pyermit*o,'
SOUTH WINDSOR, CT 06074
f Date of Expiration `
Permit Expires
APPO
E ICATIO R PERMIT �----�-
,
k Name and address of applicant T Plloae No. a
f Location of proposed work
Describe fully nature of permit requested aAAit
Insurance on file witr Town es no ate policy expires
a M Name of Insurer
o n Approximate time or completio D. esirod starting' - to 7 ...
Call before you dig ticket M.
u
= a Show sketch of proposed work or furnish 2 copies 'of separate drawings k
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a# Y 14J7
f i . A
7171
OSHA REQUIREMENTS MUST BE FOLLOWED
} Applicant is responsible forcontacting the Polio Department and CALL BEFORE YOU D
furnish IG.
I agree to ish to the Town of South Windsor the amount of bond or deposit required and t+b
reimburse the Tons of South Windsor for any expenses inmrred'by the>I O" for nu&tenanee or rrepa�r '
work in coaneWbd, with this pernut and that I am fam0iar with and ww abide` by the ivies arid:
_ regulations for permits as cwtlused in the Town of South-Wifi a s (Pa t Cnt Regaiatio s:) -
-- T -, - - -
' Signed
now
. ' APPROVED. _DATE PRQVED: _DATE
r
Supt. o Highways' . Town ngiaeer
FO NSPECTOR: Date. work started Date o
is;ient not ication recexyed: yes no ype of rep4ir Perth. Temp.
Unusual conditions encountered -
} -Viaterial.__slipisattached: yes no Dated for Permanent repair
- -
p' -
` Signed
s ;etoF 7 .