HomeMy WebLinkAboutRepair gas line Street Cut Permits 14 Pa - BOND
TOWN OF SOUTH WINDSOR N° 1016
Am It Req. PUBLIC WORKS DEPARTMENT Date
TOWN HALL
't on File 1540 SULLIVAN AVENUE Permit No.
SOUTH WINDSOR, CT 06074
Date of Expiration Permit Expires__
APPLICATION F� PERMIT
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Name and address of applicant__. /,f., �,: [3„q.p Phone No �.�9. ,2.Z36
Location of proposed work
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F Describe fully nature of permit requested
Insurance on file with Town es no Date policy expires
s~ Name of Insurer
o Approximate time for completion ( pA.,, Desired startin date
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Call before you dig ticket m.
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a. Show sketch of proposed work or furnish Z copies of separate drawings
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OSHA REQUIREMENTS MUST BE FOLLOWED
Q' Applicant is responsible for contacting the Pope Department and CALL BEFORE YOU DIG.
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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
APPROVED: DATE APPROVED:_ Engineer
DATE
Supt. of Highways py7l Town
FOR INSPECTOR: Date work started Date completed
u ficient noti ication received: yes no Type of repair: Perm. Temp. _.
-`Unusual conditions encountered
Material slips attached: yes no Dated for Permanent repair
Signed
Inspector