HomeMy WebLinkAboutWater Street Cut Permits 160 Kelly Road BOND +TOWN OF .SOUTH Wmsm
Am't Req. PUBLIC WORKS r 9PAMMT Date
TOWN HALL
-_t on File 1540 SULLIVAN AVENUE Permit No. Z.CQ04
SOUTH WINDSO& CT 06074 —'-----
Date of Expiration
APPLI ATION FOR�PERMIT permit Expires
FEE /Q � b[ 121 �o,
Name and address of applicant ' r r F--0 Phone No.
Location o propose work d ,, �, 7Describe fully nature of permit reggested
Insurance on file with Town (yes ao Date policy expires
Name of Insurer
o. Approximate time for completion 110 f f es
ired sEarting datefi a i Z f Y"i
A Call before you dig ticket rio. -
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Show sketch of proposed work or fur sh Z, copies of separate drawings
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OSHA REQUIREMENTS MUST BE FOLLOWED
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A. Applicant 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 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
regulations for permits as outlined in the Town of South Windsor's (Pavement Cut Regulations.),.-
Signed ` ,, ;-�, .-A
APPROVED:APPROVED: DATE=PROVED: DATE
Supt. of Highways o eer —"
FOR INSPECTOR: Date work started Date completed p ed
Sufficient noti cation received: yes no Type of repair: Perm. Temp.
Unusual.-conditions--encountered- — --- -- ----- -----_---------- __�_-----
Material slips attached: yes no Dated for Permanent repair
Signed
Inspector