HomeMy WebLinkAboutBLDTR-17-004859TOWN OF V R-NIOUTH
BUILDING DEPARTMENT
11.16 Route 28, South Vermouth, MA 02664
508-398-2231 ext. 261 Fax 508-398-0836
Fermit Number (U-)T1Z
Date Issued
Expiration Date
TRENCH PERMIT
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of A licant .
PP 'tq � ff �`v�
Phone Cell
Street address C(S � Pi
'5- � � `
City/Town
wb�� AIS"
IMA
ZIP
o�c!q
Nance of Excavator (if different from applicant)
Phone Cell
Street Address
City/Town
MA
ZIP
Narne of Owner(s) of Property
Phone Cell
-0
Street Address, U
(.pO.3 _ 3'�
Cit�.
ZIP 0,3L Q�J
t
Other Contact Permit Fee Received No Yes ( )
Description, location and purpose of proposed trench:c S' 5�1 Y
Please describe
the exact: location of the proposed trench and its purpog(include a description of what is (or is intended) to
be laid in proposed trench (eg; pipes/cable Penes etc..) Please use reverse side if a ditional space is needed.
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9
MAR 2 4 2011
Insurance Certificate #: CPA
Name and Contact Information of Insurer:
�i�' � Svs�"7S lG3U
Policy Expiration Date: �O /
Dig Safe #:
Name of Competent Peri -on (as defined by 520 CMR 7.02):
1 of 2
Mas: _xiasetts Hoisting License # /3�, yDo�-
yx V//
License Grade: gA Expiration Date:
BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH, OR, BEFORE COMMENCEMENT OF THE WOW WILL BECOME FAMILIAR
WITH, ALL LAWS AND REGULATIONS APPLICABLE' TO WORD PROPOSED", INCLULDIIo+G"'OSTIA REGULATIONS,
G.L. c. 92A, 520 CMR 7.00 et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BAY -LAWS AND
REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORD DONE UNDER THE PERMIT ISSUED FOR
SUCH WORD WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH
BELOW.
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND TIME
EXCAVATOR TO UNDERTAKE SUCH WORK ON, THE PROPERTY OF THE OWNER, AND ALSO; FOR TETE
DURATION OF CONS'T'RUCTION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT TETE WORK FOR CONFORMITY WITH THE
CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS GOVERING SUCH WORT.
THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE
MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF S'L'ATE LAW AND CONDITIONS OF
THIS PERMIT, INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH, AND MEASURES TAKEN BY THE
MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO
COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED
NECESSARY BY THE MUNICIPALITY.
THE UNDERSIGNED APPLICANT, OWNED AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDEMNIFY, AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM
ANY AND ALL LIABILITY, CAUSES OR ACTION, COSTS, AND EXPENSES RESULTING FROM OR ARISING OUT
OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER TIM PERMIT.
APPLICAN-T-SIGNA'ITCJ�
i � —DATE
EX V TU TFFEREAIT)
DATE
WNER'S SIGNATU M (TF D97ERENT)
kl /2c;DATE: 3 '74-21
2 Of 2
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