HomeMy WebLinkAboutRepair gas facilities Street Cut Permits BO TOWN OF SOUTH WINDSOR780
Am t Req. PUBLIC WORKS DEPARTMENT
Arn't on File
TOWN HALL FDate1540 SULLIVAN AVENUE
Date of Expiration SOUTH WINDSOR, CT 06074 ermit No.
APPLICATION FOR PERMIT Permit Expires
FEE
Name and address of applicant
L Phone No.
ocation of proposed work :h� '
Describe fully nature of permit requested r
Insurance on file with Town
N ' -eft no Date pol,
94 Name of Insurer
1 �" C." f -- Y expires ,
O Approximate time for completion
v Call before Desired startin U you dig ticket No. / g date ;
a Show sketch of proposed work or furnish 2 copies of separate drawings
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QApplicant 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
reimburse the Town of South Windsor for an expenses de
work in connection with this Y incurred by the Town for posit required and to
regulations for permit and that I am f 'thee or repair
permits as outlined in the Town of Southfamiliar
(Pavement Cutwill e Regulations.)t� m ad
Signed 9 A
APPROVED DATE
Supt. of Highways ------APPROVED:
DATE ,>
77�-'Town ngineer
FOR INSPECTOR: Date work started
Sufficient notification' received: Date completed
Unusual conditions encountered yes no Type of repair: 'Perm.
Temp.,.
Material -slips attached: yes no . Dated for Perri anent repair
Signed
spector