HomeMy WebLinkAboutBLDTR-19-000764 TOWN OF YARMOUTH . ( D7TZ-/�1-�76/
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6 �. toBUILDING DEPARTMENT
Permit Numberer
D ' ', C" 1146 Route 28,South Yarmouth,MA 02664 '
? t • 508-3982231 ext. Fax 508-398-0836 Date Issued
. %),:47::::„.„.,:47: 'r. .
Expiration Date
AdamRiker
PO Box 726 $50.00.OQ
5outh Ycrmouuth,MA 02664
• TRENCH PERMIT
Pursuant to G.L.c.82A §1 and 520 CMR 7.00 et seq.(as amended)
TIILS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Pismo ofaPPlicant g;Ker 6c11c1 CnSirtici..'c•^ P1O°0
Cell
77N83t0'6 /0i Stif
re 774-6 940
Street Address
PO
302( 7d 4 Email Address: r;ler(ells/i✓ekre^fig ya lee.ern
City/Town MA ZIP
1
Name of Excavator Of different from applicant)
Phone Cell
Street Address Email Address:
Cityffown MA ZIP
Phone Cell
Naa�eotoV:Tick orPrapert/ 50f)-64`1- 7153
:Tick, Mc,,x�
Street Address Email Address:
93 G.//1v,,,c PtiiA ZIPCity/Town
kYWno .. I x 1 oat?3
Other Contact I Permit Fee Received No( 1 Yes( 1
Description,location and purpose of proposed trench:
Please describe the exact location of the proposed trench and its purpose(include a description of what is(or is intended)to
be laid in proposed trench(eg;pipdcabie lines etc..)Please use reverse aide if additional space is rattesteR. d. C I
/j l G/�c ,n�. raft,
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MENT
^ Feet 0F 9,cpc,i, re, .SCP 17e
Insurance Certificate It; 6,Z Zt. (3 _ a a053 gS-s' 0
j Name and Contact Information of Insurer: 97$'•14-9144 i(13 nevi. Sire i'
Fos lcr- £l1;vet, 1 st.A42/rC Ncj* Optio '/s:9 oibe
: Policy Expiration Date: 0)/PIAo on J
Dib Safe M: 0 ////320 - 77L/)
Name of Competent Persoo(nplas Mined by SID CCR 1.U21:
Name of Competent Person(as defined by 520 CMR 7.02):
ASG . R Ri 1:cr
Massachusetts Hoisting Licensee I4 E - £23 cd3
License Grade: 319 i JC Expiration Date: CW r�0I
BY SIGNING THIS FORM, THE APPLICANT, OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF THE WORK,WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,
G.L. c. 82A, 520 CMR 7.00 et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND
REGULATIONS AND Ilia COVENANT ANDG E•T"THAT
RESPECTS ALL WORK DONE AND WTTHUNHE THE
PERO S SSUE FOR
OR
SUCH WORK WILL COMPLY THEREWITH
BELOW.
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO, FOR THE
DURATION OF CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER WORK FOR CONFORMITY
CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULAPROPERTY TO MONITOR AND INSPECT TIONS COVERING SUCH WORK. WITH THE
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AN)EXPENSES INCURRED BY THE
MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT EMITTED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS BYAKEN S OT FF
THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES
E
MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO
COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REyIEDLa yE A SURFS DEEMED
NECESSARY BY THE MUNICIPALITY.
THE UNDERSIGNED APPLICANT, OWNER 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 THIS PERMIT.
APPLICANT SIGNATURE
.07442b—
EXCAVATOR
0EXCAVATOR SIGNATURE(IF Dl!!ELRENT)
OSQQ'• DATE
L u It
OWNER'S SIGNATURE(IF DIFFERENT)
L .t *ATE: 6VO4A,
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