HomeMy WebLinkAboutBLDTR-19-000838 IC-- ,ot'YAR TOWN OF YARMOUTH i LB(,0'T-{Q -S3 r
! 4, ,. t r BUILDING DEPARTMENT • Permit Number
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• '•g y 1146 Route 28. South Yarmouth. MA 02664
, %.:, ,,y� r <t18-378.223) e%t.1261 Fax 508-398-0836 Date Issued
Expiration Date
$50.00 •
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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 Applicant/I iu:ie. ,,.,d ithercr, Phone Cell
Street Addrms p1, id -I oi pc) , , 8•398 •d4RP 13•3cDP-1t7)o
C /row INA I flP •
Name of E razor(if diff from applicant) �
t ip- QPhone •Cell
Street Add r Vt I 1 .5be• 9g9 - 847
157 - t &i i L,i.�;e. •
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CityFfp.rn •
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Na`m�ey(Jo�ff�Ownerys pro Oat, J f
Property Phone .CeB - .
Street AddressCkyfro 6 �t� •
^ MA ZIP
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Oth 'Contact Perndt Fee Rented No l 1 Yes( 1
Description location and purpose of proposed trench:
Please describe the matt location of the proposed trench and its purpose(Include a description of what is(or Is intended)to
be laid in proposed trench(em pipes/cable lines des.)Pleaseµse reverse side If additional space Is needed.
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i Insurance Certificate St ry^ I' AAn Y n a
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Names Contact Information of Insurer:
revs awt 69 , )%tun n.>+.e.. 569. -398.•7,1 .7
: Policy Expiration Darr.. . 10 40/9) •
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Name of ompetept Person I • net by S20 CMR 7.02):
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Massachusetts Hoisting License 0 #Edfl'52P- -
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License Grade: , ,�-'x-13' ( aj��( r
} E ./ration D'stC -
BY SIGNING t
THAT NY ARE FAMILIAR
FO�THE*Man OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CErtrY
WITH;OR;BEFORE COMMENCEMEN] OF TEE WORK,WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDLNG OSHA REGULATIONS,
G.L. c. 32A, 520 CMR 7.00 et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES,
REGULATIONS AND THEY COVENANT AND AGREE THAPALL WORK DONE UNDER 1flfliZMLP ISSUED FOR
SUCH WORK WSL COMPLY THEREWITH IN/ ALL RESPECTS AND WEIR THE CONDTTiONS SET FORTS
BELOW_
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO 'APPLY FOR THE PER= AND THE
EXCAVATOR TO UNDERTABE SUCH WORE ON TEE PROPERTY OF TRE,OWNER, AND ALSO, FOR THE
DURATION OF CONSTRUCTION; AUTHORIUS PERSONS DULY APPOINTED BY THE MUNIany. l r TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE
CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH WORE
TSE UNDERSIGNEDAPPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REmBIIRSB TEE MUNICIPALITY FOR ANY AND ALL COSTS AND ESPENTSES,INCURRED BY THE
MUN IOPALTTY IN CONNECTION WETS TRIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDINGUT NOT LIMITED TO ENFORCING IRE REQUIREMENTS OF STATE LAW AND CONDITIONS OF
TMUNICIPALTTY HIS
DEQ TEC ONS M&J ET ULIC COMPLIANCE :AND MEASURES TAKEN BYTHE
COMPLY THEREWITH INCLUDING POLICE ERE� T P�PPLICANT OWNER ux.M�D�FAILED TO
NECESSARY BY THE MUNICIPALITY- f
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TEE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND
ANY AND INDEMNIFY,AND HOLD Y.ESS THE M�CPALITY AND ALL OF ITS AGENTS LY TO DEFEOD
OF ANY ALLUSJL Y,CAUSES OR ACTION,COSTS,AND EXPENSES RESULTING FROM EMPLOYEES FROM
CONDUCTED UNDER T�PER ,OR DAMAGE TO ANY PERSON. OR PROPERTY DIIRTNG TH8 WORE
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APPLICANT SIGNATURE ,
4i / DATE a + •
D► CAVATbR SIGNATURE QP D •
NIFFERENT) .,
DATE
A , „ • ,, / (SI
O ` '` 1'f-IGNATURE(I& Det
I �rL f DATE: 9 �e1
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PERi4Lfl`APPROVED BY FeeetyiTewa�–DenetwriteltMssection .
$L—.'—AB Fee-
Y • . Rant •CONDTIONS KAP>Vgg� , rO. .
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