HomeMy WebLinkAboutReplace stripped valve to blowout Street BOND TOWN OF SOUTH WMSOR
An let Req. PUBLIC WORKS DEPAR7MMT Date
TOWN HALL
It on File- IW SULLIVAN AVENUE -Permit No. zo
SOUTH WINDSOR,CT 06074
Date of Expiration Permit Expires
APPLICATIO OR PERMIT
FEE
Name?apid 4iddress of applicant Phone No Oq 67 -.13 J
Sol
Location o proposed work
Describe fully natu of permit requested
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Insurance on file with Town es no ate policy expires
Name of Insurer
0 Approximate time for comp tion Desired starting to
Call before you dig ticket No.
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^; Show sketch of proposed work or furnish 2 copies of separate drawings
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0
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:: OSHA REQUIREMENTS MUST BE FOLLOWED
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d Applicant is responsible for contacting the Police Department and CALL BEFOkE YOU DIG.
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 Vtti&
APPROVED: DATE APPROVED: A4P DATE /1014 .
Supt. of Highways �� Town Engineer
FOR INSPECTOR: Date work started Date completed
-�--- - _
u__ivient noti-ication received: yes no YPe of repair: Perm.
Unusual conditions encountered
Material slips attached: yes no Dated for Permanent repair
Signed
Inspector