HomeMy WebLinkAboutRepair broken water main Street Cut Perm (17) •II-
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1600D To v of sou YV Y. o :
�WINDDSOR;
Am"it Req. PUBLIC WORD$ DEPA T 'T :.Date
TOWN HALL
!t on File 1540 SUU IVAN AVENUE sRerrnit No.
SOUTH WINDSOR,Cr 06074
'Dte_ of Expiration r
.11errnit Expires
APPLICATION FOR PERMIT
FEE 61
lYa an address,of app ' ant Phone No.d qc�9_
Location o proposed work
Describe Fully nature of permit requested t r'
Insurance on i" a with own no ate policy expires
t Name of Insurer f .�
o; Approximate time for complet' in Desired starting to t
.: Call before you dig ticket 110.
. p.
Show sketch of proposed work or furnish 2 copies of separate drawings
�
t
OSHA REQUIREMENTS MUST BE FOLLOWED
f Applicant a.responsible for contacting rhe.Police Deparcmenr and CALL BEFORE YOU DIG.
I agree to furnish to the Town of South Windsor the amount of bond or deposit r"uired, and tof
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 fare with snd w n abide by the rules arid'
regulations for permits as audined in the Town of South Windsor's (Pavaaent Cut Regulations:►
Signedy4Z�_
4 f APPROVED. DATE APPROVE DATE �� •
Supt. H ghways To eer. Y.
FOR INSPECTOR: Date work started Date completed
z p
Suff! ton received: yes no ype o repair: Perm. a pt
rsu 1r:t iniditioas-:ehcounter-ed
Material"slip a'attached: yes no Dated for ermanent repair
Signed
40
F.
. spector