HomeMy WebLinkAboutTelephone Street Cut Permits 532 Strong s '-S r .,. -i'a• ray..y4k J,.:• •-•'-t -a. r .. . .. %,a v:.Tr': ..
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soND TOWN' OF SOUTH WWII x.
Ain't Req. PiJ$LIC WORKS DPARTEN'T'
TOWN HALL Late
It on File 1540 SULLIVAN AVENUE
Permit No.
SOUTH WINDSOR, CT'06074 ; _,
ate' of Expiration-, Plesmit Expires
APPLICATION OR ERM
.. IT
FEE
Name and address of ePpIt ant P `oaeNo. �mG/� ,+ ' /.
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ocation of proposed work `
Describe fully nat re'of permit requested --c' ,Y�/ ',,�-Y•yy► ✓ oo
Insurance on file with Town ye no_ ate policy expires
Name of Insurer., c.0 y
{Approximate time for completion Desired starting to
Call:before-yrou dig ticket No.
Show sketch of proposed work or. furnish 2 copies of separate drawings
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OSEA_REQUIREMENTS, MUST BE FOLLOWED
Applicant is rtsponstble for contacting the Polio Department and CALL BEFORE YOU DIG.
' I agree to furnish to the Town of South Windsor the amount of bond or de i posit required i�nd to
reimburse' the flown 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 *W abide by riflee atlul_
reEtalations for Permits as eudined in the Town of South.'Window (Pavement Cut ' ns,)
Signed
APPROVED:` DATE APPROVED:. ) DATE
Su t. of Highways _w"'"__'
t
P �� Town Engineer
FOR-INSPECTOR: Date work started Date `o
mpleted
icien , no i ca ion receive yes no Type of repair Perin. T IV
p
" EJtkiral coin oas encountered
Material slips attached: yes no Dated for Perinanent repair.
Signed
Spe,t