HomeMy WebLinkAboutRepair wires on gas main Street Cut Perm { TOWN OF SOUTH WINDSOR 7 6 0
BOND - -
I7Amtt Req. PUBLIC WORKS DEPARTMENT Date
TOWN HALL
It on File 1540 SULLIVAN AVENUE Permit No.
SOUTH WINDSOR,CT 06074
Date of Expiration Permit Expires
APPLICATION FOR PERMIT
FEE
Name and address of applicant Y,4,YJK� CAS Phone No K--2l-
Location of proposed work Cl/,-,C.,r ",
Describe fully nature of permit requested__' , -t4,�
Insurance on file with Town des no Date policy expires
Name of Insurer �� �� S
o Approximate time for completion / �,q -P• Desired starting date
a Call before you dig ticket 11o. 41 / �
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Show sketch of proposed work or furnish 2 copies of separate drawings
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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 (Pavement Cut Regulations.)
Signed cr
APPROVED: DATE APPROVE ` DATE`5/-�411j//
Supt. of Highways T"ng er — —
FOR INSPECTOR: Date work started Da
te completed
Sufficient notification received: yes no Type of repair: Perm. Tee;"
Unusual conditions encountered
Material slips attached: yes no Dated for Perri anent repair
Signed
In# ;ector.