HomeMy WebLinkAboutBLDTR-19-000856 •
;oF:YgR TOWN OF YARMOUTH dci-�C(J�O
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BUILDING DEPARTMENT Permit Number
p( tilt: y 1146 Route 28,South Yarmouth, MA 02664
�;mt i„ , _t' 508-398.2231 ext. 1261 Fax 508-398.0836 Date Issued
Expiration Date .
$50.00
TRENCH PERMIT
Pursuant to C.L.c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Appikant wloccc B . Ow_ co Ph0ne ceu
Street Address SVR— 93 a o S
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Ct own MA ZIP
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Name 44y/cantor lit diR��from applicant) Phone Cell
Street Address
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Name of Ownerts)of Property Phan Cell
Street Address yrVIM€
City/Town 3 S7-€401 A (-'3 Sob- 3(0‘)-- 4g91-13
MA I ZIP
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Other Contact I Permit Fee Received No 1 ) Yea l )
Dncriplon,kxatloa and purpose of proposed trench:
Please describe the exact location of the proposal trench and its purpose(Include a description of what Is(or Is intended)to
be laid In proposal trench leg;pipes/cable lines etc..)Please use reverse dde If additional space Is needed.
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AUG 1420181
Insurance Certificate Mt c@ BUI(DI P.tRS. -
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i Name and Contact Infnrmaann of Imurert
I4\ S INtert02G'T:1OpRL hitt) ?...11.1
Polky Erpintkrt Dates 3.4 1 I i b
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Nang of Competent Perms t as defined by 520(MR).021
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Grades Ftp— [63(,fl PKV Expiration Date:
BY SIGNING 11115 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,
CL c. S2A, 520 CMR 7.00 et 7tab AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND
REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR
SUCH WORK WILL COMPLY TI;EREWTIH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH
BELOW.
TUE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WORE ON THE PROPERTY OF THE OWNER, AND ALSO, FOR THE
DURATION OF CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE
CONDRIONS 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
MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS Of STATE LAW AND CONDmONS OP
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,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 SI e)(3/)r
DATE
EXCAVATOR SIGNATURE )RE(IF DIFFERENT)
•PKn(3 -tti4• DATE �V13116
OHNE 'S SIGNATURE(IF DIFFERENT)
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