HomeMy WebLinkAboutInstall 6 D.I.P. sleeve Street Cut Permi aalvn` TOWN O SOjJ" WINDSOR p'
m't Req. PUMC WORD DEPAR
—,---- 7�EINT -pate
z TOWN HALL
It on File 15�40 SULIIVAIV AVENUE
U SOUTH.WIN Permit No.
r
Date of Expiration
DSOR CT 06074
yAPPLICATION FOR P Permit Expires
� FEE Q-- ERMIT
F' Name and address of applicant y�
Wua+4 'R _�� o+asr�xvc r eat Ga 'home No. -��r." :Alb m t± F
Location of proposed work 1�t-�•4,, R T
Describe fully nature of perrrnit requested � s�-A �•
Insurance on file with own
yes no ate policy expires
Name of Insurerhli" N N t» bwiP
}, o' Approximate time for completion a yR esired startin
�.4 date
Gall before<Yat dig ticket t1o. ZZ. 3 7 8
J Show sketch of proposed work or furnish 2 copies Hof separate drawin 's•
8
w
o
OSHA REQUIREMENTS MUST BE FOLLOWED
o.
4 Applicant is respo"6b for contacting dte Police Dppamnent and CALL BEFORE YOU DIG.
I agree t', furnish to the Town of South Windsor the amount of bond or deposit
reimburse.the To" of South Windsor for any ezpenses incurred b . the Tovin far required ,an¢ to
work to
too Windsor with thus Y + tenance or repair permit and that I am fam0 ar With and wo
regulations for puts as outlined in the Town of South Windsor's (Pavement Cast by the rubs anti
�Regnh�ttions,
Signed l;
APPROVED-_ __DATE APPROVED-
Supt.Of Highways DATE
o'
�iAe r
FOR INSPECTOR: Date work tatted Date cornpleted �.u icient not" "ration received: es
` Y no Type—of repair: Perm. ,Te
. Unusual conditions encountered - - - �P•
Material slipli attached: yes no Dated for Permanent repair
Signed.
-Tva di
or