HomeMy WebLinkAboutMain break Street Cut Permits 22 Hazel D BOND TOWN OF SOUTH WINDSOR
Am't Req. PUBLIC WORKS DEPART)MT Date
TOWN HALT;
It on File - 1540 SULLIVAN AVENUE Permit No. c -----
SOUTH WINDSOR,CT 06074
Date of Expiration
APPLICATIO FO PERMIT permit Expires
FEE
Name and address of applicant of Phone No � � `J 5j� 2
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Location of proposed work
Describe fully nature of permit requested
Insurance on file with Town es no Date policy expires
c Name of Insurer
o Approximate time for completion Desired starting date -
Call before. you dig ticket Tdo. 6 J A j 4(7 C U 0.T -f b
a.
Show sketch of proposed work or furnish 2 copies of separate drawings
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^; OSHA REQUIREMENTS MUST BE FOLLOWED
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Q Applicant is responsible foe 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
l reguations for permits as outlined in the Town of South Windsor's (pavement Cut_ Regulations.)
Signed
APPROVED: DATE APPROVE DATE111
5upt.of IH- ighway$ o Weer
FOR INSPECTOR: Date work started Date completed
Sufficient noti icition received: - yes no -- ype-of repair: Perm,
__ - --Unusual conditions-encountered - - -- --- - -- - - - - ------- --- -- ---- - ---
Material slips attached: yes no Dated for ermanent repair
Signed
spector