HomeMy WebLinkAboutRepair gas main Street Cut Permits Rye a .. •.. .. ..: ..a r... :.. .: .y,. Ij,...:'4R i '
BOND TOWN OF SOUTH MnMSOR
Am't Req._ PUBLIC WORKS DEPARTMMTDate
TOWN HALL
It on File 1540 SULLIVAN AVENUE -Permit No. ZOOS-
SOUTH WINDSOR,CT 06074
Date of Expiration Permit Expires
APPLICATION OR PERMIT
FEE
Name and address of applicant Q totg . �?CAL-� Phone No.
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Location of proposed Work f
Describe fully nature of permit requested
assurance on ile_;with Town zmo no Date policy expires
Name oCInsurer A\ Q L�& --
Approximate time for co pletion } `{ f , Desired starting date
Call before you dig ticket Ydo. Ry---) 1SZ:!�6 7
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Show sketch of proposed work or furnish 2 copies of separate drawings
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OSHA, REQUIREMENTS MUST BE FOLLOWED
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4 Applicant is responsible for contacting the Police Depantnent 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 abide by the rules and
regulations for permits as outlined in the Town of South Windsor's (Pavement Cut Regulations.)
Signed L d ,41c:�r,q
APPROVED: - DATE APPROVED: DATE 0,4"tt
Supt. of Highways Town Engineer
- -*:0,R INSPECTOR.: Date work started Date completed
u _ident_note acation received: yes _`no _ _ype of repair: Perm.
Unusual conditions encountered
Material slips attached: yes no. Bated,for Permanent repair
Signed
spector