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BOND TOWN OF SOUTR WINDSOR
Ulu
Ain't Req._ _ PUBLIC WORKS DP"ARTMENT Date
TOWN HALL
It on File 1540 SULLIVAN AVENUE Permit No.
t SOUTH WINDSOR, CT 06074
.Date of Expiration Permit Expires
APPLICAT R
0A0 I ER,MIT
FEE' $1
Name and address of applicant /`I . - 4"MPhone-No.PP w
Locat o ,` roposed work 6 t.
escribe fully natur of permit" requested J
aAl UUrQjG�U
Insurance on fie with Town ye-s_ no Date policy.expires
Name of Insurer .
Approximate time;;. Desired startn date
Call before-you did' Wicket Poo. d t; G
Show sketch f proposed work or furnish 2 copies of separate drin'
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Applicant is responsible for contacti the Police Departmen�and ALL BEFORE YOU DIG. S
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 or 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.)
Signedr
APPROVED. DATE _APPROVED: / ,� DATE ��/"`�U.
Supt. o Highways Town'Engineer
FOR INSPECTOR: Date work starteid Date-complete _
Sufficient notfication-received: yes no Type of repair: Perm', Tempe
c ions-eficoufifere
__.
Material slips attached: yes no Dated for Permanent repair
.Signed
r Inepctor'