HomeMy WebLinkAboutInstall approximately 72 of PLS service BOND TOWN OF SOUTH WINDSOR N2 _ - 860
Am't Req. PUBLIC WORKS DEPARTMENT
TOWN HALL Date
m't on File 1540 SULLIVAN AVENUE
SOUTH WINDSOR, CT 06074 Permit No.
Date of Expiration
APPLICATION F R PERMIT Permit Expires
FEE
Name and address of applicant y ji
L fi>)1C
T i Phone No c `f
Location of pir posed work' ,
Describe fully nature of permit requested
Insurance on file with Town yes no Date policy expires
c Name of Insurer ` ;;
o Approximate time for completion -' Desired starting date �, :
Call before you dig ticket 11o.
o,
04 Show sketch of proposed work or furnish 2 copies of separate drawings
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a ! G
o '
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V.
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 Windsor's (Pavement Cut Regulations.)
Signed.-
APPROVED: DATE APPROVED: DATE
Supt. of Highways V4V'l Town Engineer
FOR INSPECTOR: Date work started Date completed
Sufficient notification received: yes no Type of repair: Perm. 'I'ernp. —
Unusual conditions encountered..._._:_w
1GCaterial slips attached: yes no Dated for Permanent repair
Signed
Inspector