HomeMy WebLinkAboutDriveway Street Cut Permits Lot 23 Perri QN F':TOWN . OT' J
�An!t'Req. PUBLIC WORKS DEPARNr
'TOWN HALL [JI'a540 SULLIVAN AVENUE !io.SOUTH WINDSOR,'`CT 06074e ¢f Expiration mit Expires
APPLICATION F PERMIT
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- FEE _ ,
Name and address of applicant '$ Ph01%
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Location of proposed work '
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escribe fully nature of permit requested
r Ingurance on ile with own no ate policy expires ---y-- -T
c' Name of Insurer
o ' Approximate' time q m . e o Desire ,'.starting to
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Call before you dig ticket No.
' Show si�etch:of proposed ,work or furnish 2 copies of separate drawings
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OSHA REQUIREMENTS MUST BE FOLLOWED {
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 snd to
reimburse the Town.of South Windsor for any expenses incurred by the Town for maintenance""r or repair
work in connection with this permit and that I am familiar with sad :abide :by, tl>iq ,files is
regulations for permits as outlined in the Toxin of South Windsor's IPevsv&=t Cnt'Ragnlatio>y�sa
" Signed x' ✓
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Y PPROV_ED: DATE _APPRO D SATE J
Supt. of Highways Town JEngineer -"+
$" ._
R INSPECTOR:_-Date work started : Date 6om leied
. Suffic i cation-received.•
P
ges- - -no ype of-repair:Per
:Unusual conditions encountered
llitaterial`s ips attacked: yes no Dated for ermanent repair
77
Signedwooctor
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