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TOWN HALL
r 't`on File 640 SOUIVAN AVENUE
SOUTH WINDSOR Cr 06074 r
`Dante of Expiration s"P}ermit Expires t
APPLICATION OR ERMIT '-�--` '
FEE ,_
Name and address of applicant ; Ploae hio.. zZ t► ,
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' Location of propos work
Describe fully nature of permit requested
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Insurance on, file with Town des no Date e
policy
expires
�z Name of Insurer_ An a l
i Approximate time for completion f .- �� _ f Desired tarti�t `
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v Call before 'YW dig ticket No. c7 3<_/j o xs �
iShow sketch of proposed work or furnish 2 copies of separate drawings ,
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0$HA REQUIREMENTS MUST PE FOLLOWED
nt is responsible for contacting the Police Department and CALL BEFORE YOU DIG. _
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I' agree to furnish to the Town of .South Windsor the amount of bond or deposit e�equired and
reimburse'the Town of South Windsor for m exp
enses penses incurred by the Toxin fin• riutintenance or rsp�r • ;. .
work in connection with this permit and that I ani faM with and � abide by the r lea .anti
ry regulations for pftmits'as oudined in the T"n of South Windsor's ai t Cut tYo
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Signed
APPROVED: DATE APPROVED: DATE U
Supt. of Highways: o # e!
- -
FOR INSPECTOR: Date work started Dato completed
4 zcient noti ication received yes no _.er�h - T-CM,
Unusual conditions encountered
__Material slips attached: yes no Dated for Permanent repair -
Signed
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