HomeMy WebLinkAboutGas Service Street Cut Permits 413 Pleas WN
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in xfe PLIC'WORDS DEPART'
Date
't on File TOWN HALL ,
1540 SULLIVAN AVENUE Permit No.
Date of Expiration SOUTH WINDSOR, CT 06074
APPLICATION FOR PERMIT 'Permit Expires
PEE .
Name and address of applicant
Phone No. 2 9z 4 a
-57
Location of pr sed work , ,
Describe fully nature of permit requested.
Insurance on file with Town es no n
Name of Insurer Y�n _2_
ate policy expires
oApproximate time for m leti
p - 20 lie esired starting to /_
Call before you dig ticket P�To. 2 S"U ?� -Y-- -L `e.
Q. Show sketch of proposed work or furnish 2 copies of separate draw`'
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Q 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 requi>ed Ind 6
reimburse the Town of South Windsor for any expenses incurred by the Town for maintenance o re
work in connection with this permit and that I am familiar with and will abide by '.the rues and
regulations for permits{ as outlined in the Town of South Windsor's (Pavement Cut .
Rgta ktms.) x
Signed
APPROVED: DATE
APPROVED: DATE /Z-'��
Supt, of Highways ���` Town Engineer
FOR INSPECTOR: Date work staff ed
ufficient noti ication received.
' Date completed
Y $ no ype of repair: Perm. '�"'"'.`:�
Unusual conditip s;enco_u ter_ed. mp
Material slips attar h s.d.* yes no Dated for Perma ients repair
( Signed t