HomeMy WebLinkAboutMDC patch work Street Cut Permits Sulliv y i BOND TOWN OF SOUTH, WINDSOR N _ 798
Am't Req. PUBLIC WORKS DEPARTMENT Date
—� TOWN HALL
mtt on File 1540 SULLIVAN AVENUE Permit No.
SOUTH WINDSOR, CT 06074
Date of Expi ation
Permit Expires
APPLICATION o OR PERMIT
Name and `address of applicant v 9&<- Phone No, 64-3 737c
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Location of proposed work /."I a6c-Al tlS e
Des ribe fully nature of permit requested 9 t4"0/—<.
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Ins ranee on file with Town P
no Date policy expires
o ; Na a of Insurer s ti
o ` Ap 'roximate time for completion / Desired starting date // 4
Cal before you dig ticket No.
a or furnish 2 copies of separate drawings
#Show sketch of proposed work
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Applicant 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
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 0
yement RegQlationa.
Signed
APPROVED: DATE APPRO ED• DATE
Supt. of Highways o n ineer
FOR INSPECTOR: Date work started �/ Date completed
Sufficient notification received: yes no _ Type of repair:- Perm.- - Temp.-
Unusual conditions encountered
Material slips attached: yes no Dated for Permaltent, repair
a i
r Signedit
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