HomeMy WebLinkAboutGas Service Street Cut Permits 986 Pleas BOND TOWN OF SOV 0'DSOR
Amt Req, PUBLIC WORKS DLPARI] NT
gate
TOWN.HALL
` It on File 1540 SULLIVAN'AVENUE Kermit No.
SOUTH WINDSOR.CT o6o74
u
Date of Expiration
]?ermit Expires
"PLICATIO ERMIT
FEE
Name and address of applicant q � . F one No, 29
1 G t�L1 E -
Location of propo work -
T Describe, fully nature of permit requested �� � c�\� c�.e. 0-C\1 r2'
nsurance on file with own es no ate policy expires
Name of Insurer
o Approximate time for.comp ions ►\.3m-q 3Desired starting
w g ;ems\
Call before you dig ticket rJo. j 3Lj 5 4-"
f Show sketch of proposed work'or furnish 2 copies of separate drawings
A
r 4 O• f -
+ � r
�10t
` {{ f
i f
OSHA, REQUTREMtNTS MUST BE FOLLOWED ---
Applicant is responsible for contacting the Police Department and CALL HEF(xitE YOU DIG. L
E . { I agree to furnish. to the Town of Sou tl► Windsor the amount of bond or deposit required and 4d
k ` ' reimburse the Town of South Windsor for any expenses incurred by the Town for,mainteWulm or ,reps,
work in connection with this permit and that I am familiar with and will abide by the ruses acid
>" regulations for permits as outlined in the Town of South 1Wi�n oWs (Pav�en*nt Cat Regaistionsa
'F Signed C lc ��
APPROVED: DATE APPROVE DATE
Supt. of Highways To "rtee r
, , --- -OR IMP-ECT-OR Date- work started _ _ Date �ompiete�i�. . ._
y'e8 no �Kpe �f r�pur:—P._erir�,�
Unusual.conditions EIICOUntered
Material=slips'-attaehed: 'yes ao - ated-for ermanenf repair ^_
Signed
- or