HomeMy WebLinkAboutReconstruct intersection Street Cut Perm rq yBOND TOWN OF SOUTH WINDSOR 5 9
Am't Req. PUBLIC WORKS DEPARTMENT Date
Am TOWN HALL't on File 1540 SULLIVAN AVENUE
Permit No.
Date of Expiration SOUTH WINDSOR, CT 06074
APPLICATION FOR PERMIT Permit Expires
FEE $10.00
Name and address of applicant -�-- '�
PP �J':,��1 r.� � (,- .,�,r- Phone No
Location of proposed work F
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Describe fully nature of permit re uested
Insurance on file with Town es-> no Date policy expires F��>c,,; . f
0 Name of Insurer L, �, �,� ;1;
o Approximate time for comp
le ion r \,,";,_ - , Desired starting date --
Show sketch of proposed work or furnish 2 copies of separate drawings
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Applicant is responsible for contacting the Police Department and CALL BEFORE 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.)
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APPROVED:
DATE APPRVF '! DATE
Supt. of Highways ( Tu
\ wri gineer
FOR INSPECTOR: Date work started Date completed
Sufficient notification received: yes no Type of repair: Perm. Temp.
Unusual conditions encountered
Material slips attached: yes no Dated for Permanent repair
Signed
Inspector
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