HomeMy WebLinkAboutInstall telemetering box Street Cut Perm BOND TO" OF SOUTH WINDSOR
Am't Req. PUBLIC WORKS DEPARTKENT Date
TOWN HALT,
It on File 1540 SUL11VAN AVENUE
Permit No.
SOUTH WINDSOR,CT 06074 ---
Date of Expiration Permit Expires
APPLICATION FOR PERMIT
FEE -
Name and address of applicant , �./I�-- _(_2 Phone No.
Location of proposed work
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Describe fully nat re of Sermit;xequested t c
Insurance on file with Town es no ate policy expires -/-
Name of Insurer
.oc. Approximate time for completion Desired starting date
b Call before you dig ticket No.
u /373
V" Show sketch of proposed work or furnish 2 copies of separate drawings
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OSHA REQUIREMENTS MUST BE FOLLOWED
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Applicant is responsible for contacting the Police Departawat 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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Signed
APPROVED: DATE APPROVED: DATE 'Y�,iP,
Supt. of Highways . Tow; engineer
FOR INSPECTOR: Date work start ed Date completed
u icient noti ication received: yes no
30.
Unusual con itions encountered
Material Bli s attached:p yes no Dated for Permanent repair
Signed ,
Inspector