HomeMy WebLinkAboutMDC patch work Street Cut Permits Chapel A N2 _ 796
OND'` TOWN OF SOUTff. WINDSOR
a.
Am't Req. PUBLIC WORKS DEPARTMENT Date
TOWN HALL
Mot, on File, 1540 SULLIVAN AVENUE Permit No.
' SOUTH WINDSOR, Cr 06074
Date of Expilation
APPLICATION FOR PERMIT Permit Expires
FEE
II
Name and addres of applicant o 9&,,!c Ph �o ne No. 370
Location of work
proposed Gv sC,e z Lv 4.
Des Jribe fully nature of permit requested.
Ins `rance on file with Town ye no Date policy expires
7 Narfe of Insurer Awe& 15Udafs «�
o ! Ap `roximate time for completion I Desired starting ate
d u cal before you dig ticket PJo.
aShow 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 deposit required and to
f 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 (Pa ement 94 Regulations.)
Signed /Av
APPROVED. DATE APPROVED, DATE // /L d`7
Supt. of Highways o n ineer
4FOR INSPECTOR: Date work started Date completed
Sufficienit notificatyion received: yes. no Type of repair: F-:c
Unusual conditions encountered
Material slips attached: yes no Dated for Permapent repair
jot
�.. Signed.. y