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BOND TOWN OF SOUTH VVINDSOR 0963
Am It Req. PUBLIC WORKS PARTkOW
TOWN HALL Date
It on File - - 1540.SULLIVAN AVENUE. . - - Permit No.
Date of Expiration SOUTH WINDSOR,CT 06074
-
APPLICATION FOR PERMIT Permit Expires
FEE
Name and address of applicant `
PhQue No. a y30 3 q'
Location of proposed work
Describe fully nature of per ` it reque ted
Insurance on ile with Town no ate policy expires
Name of Insurer r 9
Approximate time for com `letion esired starting to
Call before you dig ticket t1o.
a. Show sketch of proposed work or furnish 2 copies of separate drawings
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OSHA.. REQUTREMENTS MUST BE FOLLOWED
4 Applicanc is respotnible.foe contacting the police Depantnenc'"and CALL$F.FORE YOU DIG.
I agree to ish. to. the Town of South Windsor the amount of bond'
fnn or deposit required :and to
reimburse the Toga of South Windsor for any espenses incurred by the Toft fur main
work' in connection with this tenanoe or repair
permit Bed 'that ;1 am famdir with and abir�e by the niies arui
regulations for permits as ouWined in the Town of South Vlliridspr's IPawpt .Ca6 latons.)'
Signed
APPROVED: DATE AP .ROVED• DATESupt. of Highways o weer
of
FOR INSPECTOR: Date work
started Date-completed
u icent note ication received. es no , Xpe of re__pair_ e ,
----- --Hmrsual coral#tiuifiis encountered y:- -- --
Material, slips attached: yes no Dated for errtianent repair
Signed- I
director