HomeMy WebLinkAboutGas Main Street Cut Permits Graham at Ne (2) .0941
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•A '! Req. PLIBI' C ifOR S DEPART fly,
' HALL t on File
, ate
TOWN
1540 SULLIVAN AVENUE
SOUTH WIINDSOR CT 06074 I'errriit No.
Date of Expiration • � >
7
APPLICATION FO PERMIT' E?ermit Espi ree
FEE
s Dame and address of applicantI C
K� .,'''fit, 4
Phone No. Q
Location o proposed work
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Describe fully nature of permit requested
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Insurance on i e with Town' es no
i c' Name of Insurer y ate policy a i5res
ti ,�`,'a. Approximate time focom�pletion,
Call before You digstar + ,
esired tin to-ticket r1o, �3?j'"'D$"] 7
Y
Show
a sketch of proposed work or furnish 2 co
p es of separate drewings
/75
. $
Atg
" OSHA REOUIREMENTS MUST BE FOLLOWED tit '
- - _Ptiliunc is sible for contacting-the police Die
4, _respon pantnenc and CALL BEFORE YOU DIG.
I _agree to furnish to the Town of South Windsor the amount of bo f
reimburse the Town of South W' deposit tiegditeid end'to
work in counfttion with this Windsor for aay ezpenseg incurred by the Toyen for.main
' refiulations for Pechti Permit and that I am h mgkr with and abide tauuaace or,�,
to as outlined in the Toren of South Windsor's IPa ul?e3 a{s _
re> ent Cut Regalaitions.►. a"
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Signed �fi i
t..
APPROVED: DATE
APPROVED:. r
Supt.o ighways DATE ,lh
Own Engineer
F"OR INSPECTOR: Date work started '
u_ icient nota ication received: Date .completed
yes no _ ype of reptis�s Pernn-,
_ Unus4al_conditions encountered T,enip.
Material slips attached: yes no ated forPermanent repair
Signed
s ecCor