HomeMy WebLinkAboutMDC patch work Street Cut Permits Clark OND TOWN OF SOUTH WINDSOR N2 _ _ 798
Am't Req. PUBLIC WORKS DEPARTMENT Date
TOWN HALL
m't on File 1540 SULLIVAN AVENUE Permit No.
SOUTH WINDSOR, CT 06074
Date of Expiration
1 Permit Expires
APPLICATIONoF�OR PERMIT
Name and addres of applicant o �j/,CGS' Phone No. � 737U
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Locakion of work
proposed Gv
Des ribe fully nature of permit requested. yo
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Insitrance on file with Town ye no Date policy expires
Na a of Insurer a s A tH(
o Ap xoximate time for completion I Desired starting,date
Cal before you dig ticket 110.
4 TShow sketch of proposed work or furnish 2 copies of separate drawings
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CApplicant is responsible for contacting the Police Department and CALL BEFORE YOU DIG. <,
9. 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 (Pa ement 0,V Regulations.)
Signed
APPROVED: DATE APPRO ED• DATE
Supt. of Highways /'TofrilNineer
FOR INSPECTOR: Date work started Date completed
_Sufficient_notification received: yes. _ no Type of repair: P!4rrn,- Temp.
Unusual conditions encountered
Material slips attached: yes no Dated for Permanent repair
F Signed,.
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