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TOWN OF SOUTH WINDSOR
Am It Req. PUBLIC WORKS DEPARTMENT Date
TOWN HALL
It .on File 1540 SULLIVAN AVENUE Permit No.
SOUTH WINDSOR,CT 06074
Date of Expiration Permit Expires
APPLICATIO FOR PF .MIT
FEE a `��2
Name and address of applicant _ r Phone No.
Location of proposed work
Describe fully nature of permit requested t
Insurance on file with Town ties no Date policy expires
Name of Insurer -
oApproximate time for completion Desired starting date
Call before you dig ticket 110. f, T'-7 _
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
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.)
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Signed T
APPROVED: DATE APPROVED:....,", ,, DATE`1.1 ! <.
Supt. of Highways To%irn I�In 'veer
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 Permanent repair
Signed
Inspector