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- _ BOND TOWN OF SOUTH WI SOR
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Arn't'Req. PUBLIC WORKS DEPARTMENT Date
TOWN HALL
't on File 1540 SULLIVAN AVENUE Permit No.
SOUTH WINDSOR, CT 06074a
ate of Expiration APPLICATION FOR PERMIT Permit Expires
FEE $10.00
Name and address of applicant Phone No
Location of proposed work
Describe fully nature of permit otequested
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Insurance on file with Town es no Date policy expires
Name of Insurer !_!
oApproximate time for completion Desired starting date
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Show sketch of proposed work or furnish 2 copies of separate drawings
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14 -'
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Applicant is responsible for contacting the Police 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 ab' a by the rules and
regulations for permits as outlined in the Town of South Windsor's (PaveFe t ut egulations.)
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Signed `"
APPROVED. DATE APPROVED: J/ ATE -/ _
Supt. of Highways 77i.r Town Engine r f
FOR INSPECTOR: Date work started Date completed
Sufficient notification received: es no Ty
pe ype of repair: Perm. Temp.
-- -- - ---Unusual conditions encountered
Material slips attached: yes no Dated for Permanent repair
Signed
Inspector