HomeMy WebLinkAboutSanitary Sewer Street Cut Permits 170 St BOND TOWN OF S61nN WMSOR
Arm't Req. PUBLIC WORKS DEPARTMMT TOWN HALL Date
It on File
1540 SULLIVAN AVENUE Permit No. Z-00„3
SOUTH WINDSOk CP 06074 --
Date of Expiration Permit Expires
APPLICATION FOR PERMIT
FEE
Name and address.of applicant Vk 0 c c} Phone No .
Location f proposed work
Describe fully nature of permit requested --------------
Insurance on file with Town yes no Date policy expires_ 11
c Name of Insurer -}1t,7 j �
vor/ '. f-
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o Approximate time for completion vc Desired starting date a
Cd
Call before you dig ticket tdo. z` � 7,
a. Show sketch of proposed work or furnish Z copies of separate drawings
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b
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4,411-01
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OSHA REQUIREMENTS MUST BE FOLLOWED
a
Q 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 Win�, sParr ent Cut Regulations.)
Signed f, Lk
APPROVED: DATE APPROVED:-All DATE =?.-5=70
Supt. of Highways PAV Town Engineer
FOR INSPECTOR: Date work started
Date completed
Sufficient noti ication received: yes no Type of repair: Perm. Temp.
Unusual condstioWA encountered
Material slips attached: yes no Dated for Permanent repair
Signed
Spector