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TOWN OF SOUTH V� r1DOR'',
Am't Req. PUBLIC WORK$.DEPARTMENT Date '
TOWN HALL
m'-t on File
1540 SULLIVAN AVENUE Permit No.
F 1 SOUTH WINDSOR, CT 06074,
Date of`Explratioia �� Permit Expires
APPLICATION FOR PERMIT
t FEE.$10.00
Y Name and address of applicant y14WK1.67.4.5 Phone No t.
Location of,proposed work" _710 fr�';,:P r.,o4. cc ` Fcr
Describe fully nature of permit requested
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Insurance on file with Town no Date policy expires / ye.
Name of Insurer T —?
Approximate time eon tetxon ► j%jZ_ Desired start g date
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Ca11 before you da.g ticket tio.
Show sketch of proposed work or furni;,ii 2 copies of separate drawings
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F �a Applicant is responsible for contacting She Police department and CALL BEFORE YOU DIG. 'Or rl � pv Z10
I agree to furnish to the mown of South Windsor the amount of bond or deposit required and to
' reim e, 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
K. regu Lions for permits as outlined in the Town'of South Windsor's (Pavement Cut Regulations.)
Signed
APPROVED. DATE APPROVED: DATE
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slip Town Engineer
-VOR tNSPE10TOR: Date work started Date completed
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u fic ant nQt frc a .on`. .eo�;ived:: <y�s no ype.--of'repair: Perm. Ternp:"
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