HomeMy WebLinkAboutRemove patch Street Cut Permits Nevers R N0 804
oND TOWN OF SOUTH WINDSOR
Amit R q. PUBLIC WORKS DEPARTMENT Date
a ' TOWN HALL
't :on File 1540 SULLIVAN AVENUE Permit No.
�' SOUTH WINDSOR, CT 06074
Date of Expiration
.Permit Expires
APPLICATION F�i, PERMIT
FEE
Name and addres31 s of ap I' ant lj�f�.Y L �.�s �C ®� Phone No. y F9 '�'7%1
Location of proposed work c�� .r /sti�l.!'�� ,�.
Describe fully nature of permit requested iA
Insurance on file with Town yes _no Date policy expires
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Name of Insurer
o Approximate time for completion .' _Desired starting ate
Call before you dig ticket 11o.
a Show 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
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 (Pay
yment Cut Regun�s:)
Signed %
APPROVED: DATE APPROVED:
/ DATE 2—
Supt. of Highways ,� Town Engineer
�hFOR 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 Permanent repair
Signed
f >> _ Inspector