HomeMy WebLinkAboutTR-19-860 s.
/ .' ,Y TOWN OF YARMOUTH
0
BUILDING DEPARTMENT Permit Number
o `1.i y 1146 Route 28,South Yarmouth,MA 02664
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2' . .T 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
Expiration Date .
$50.00
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
Nan of Applicant fel C. CnoN n Phone Cell
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Street Addrev
35O 9,003e at
Cltyfrowa MA I
ZIP
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Nan of Excavator Of different front applicant) Phone (:ell
Street Address
Clty/rown I MA I ZIP -
Naar of Ownef et of Property . Phone Cell
,anet Mittal
Street Addras do of �� 7d'/- 63'9- rvrf
City/Tam MA ZIP
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(hint Contact i Pent*Fa Received No( ) Yes( )
Desmiptios,location and purpose of proposal Menthe
Phan describe the exact location of the proposed trench and its purpose(Iaeh&a description of what is(orb intended)to
be laid In proposed trench(e=t pipes/table Utes etc.)Pleas use review vide if additional space is needed.
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AUG 14 2018
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i Insurance Certificate Ns
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Mann sad Contact Infomutbo of Insurer. Ooc,i nG '- -Osl)eel .Ic&jr c"ce
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IName of Competent Penes las defined by 520 CUR 7,021r
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ueen»Credit 1 C) 'ac,^bi= Expiration Due: 6/b11/
BY SIGNING THIS FORM.THE APPLICANT, OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH4 0R,BEFORE COMMENCEMENT OF THE WORK,WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED.INCLUDING OSHA REGULATIONS.
GL e. IDA. 520 CMR 7.00 $ seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BYLAWS AND
REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR
SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SST FORTH
BELOW.
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR .THE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WORE ON nix PROPERTY OF THE OWNER AND ALIO, FOR THE
DURATION OF CONSTRUCTION, AUTHHORITr' PERSONS DULY APPOINTED BY THE MUNICIPALITY 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.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE
MUNICIPALETY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCT'®THEREUNDER,
INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS or STATE LAW AND CONDITIONS OP
THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES TAKEN BY ME
MUNICIPALITY TO PROTECT THE PUBLIC want THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO
COMPLY TLHEREWITIL INCLUDING POLICE DETAILS AND OTHER REMEDIAL.MEASURES 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
OP ANY INJURY, DEATH. LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING 'THE WORK
CONDUCTED UNDER TIDE PERMIT,
APPLICANT
SIGNA
�:-:1 DATE 47/o/,
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
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