HomeMy WebLinkAboutGas Street Cut Permits 313 Pleasant Vall b
HAND Toym OF SOUTH i �997
VVMsolt
A 't:Req. PUBLIC WORKS DEPARTUM Date
TOWN HALL
't on File 1540 SUU IVAN AVENUE PFerrr it No.
SOUTH WINDSO1t,CT 06074
ate of Expiration
Pernnit Expires
APPLICATION FOR PIERMIT
FEE
Name and address of applicant ; Pijone No4 Z 9 Z.-Z,2 y
Location o , propose ork 3
0,77
Describe fully nature of permit requested T r c e
ir. Insurance on file with Town yes no Date policy expires
Name of Insurer
Approximate time for coat 1on 5 Desired s tartno g to.,,
Call before.you dig ticket No.
.� Show'sketch,of proposed work or furnish 2 copies of sepalrate drawings
a
o _d
w
to
aye+:
rn
V -
p
OSHA REQUIREMENTS MUST BE FOLLOWED
4 Applicant is respons6k for contacting the Police Department and CALL BEFORE YOU DIG.
I agree to f vnish to the Town Hof South Windsor the amount of bond or f
reimburse the Torn of South. Windsor for an expenses deposit required ,and rm=-
y penses incurred by the TowiA.for maintenance or repair;.
work in.connection with this permit and that I am familiar with and will abide by the rulss a*
regulations for permits as outlined in the Town of South Windsor's (pavement Cat Rsgulstions.
Signed Cc2A /a ., eA q c; C L k
APPROVED: DATE APPROVED• DATE
Supt. of Highways wa eer
FOit INSPECTOR: Date work started N D
uate. oun 1_eted
f. p -=-
Unusual conditions encountered
Material` slips attached: yes no ' Dated for ermanent rep it
Signed