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BOND TOWN OF SOUTH WINDSOR
Am't Req. PUBLIC WORKS DEPARTMENT Date
t on TOWN HALL
File
1540 SULLIVAN AVENUE Permit No.
SOUTH WINDSOR, CT 06074
Date of Expiration
APPLICATION FOR PERMIT Permit Expires
FEE $10.00
Name and address of applicant /J62 h FWf J (!?/G 7/ .J Phone No > >
Location of propose work Y y
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Describe fully nature of permit requested
Insurance on file with Town yes no Date policy expires F'
Name of Insurer -
oApproximate time for completion Desired starting date
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o Show sketch of proposed work or furnish 2 copies of separate drawings %=
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CL 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 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.)
4 Signed
APPROVED: DATE APPROVED: , J/ DATE --Z.1 j
Supt. of Highwaysy,;� Town Engineer
AsommFOR INSPECTOR: Date work started Date completed
7"sufficie—ntnotific-
ation received: yes no Type of repair: Perm. Temp.
Unusual conditions encountered
Material slips attached: yes no Dated for Perman nt repair
Signed
1% Inspect r