HomeMy WebLinkAboutTR-19-717 r•YALei TOWN OF YARMOUTH I L1� %2 i9 7
1� o BUILDING DEPARTMENT Permit Num11D �D /.7
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1146 Route 28, South Yarmouth, MA 02664 •
• 4yr`v 508-398-2231 ext. 261 Fax 508-393-0836
Date Issued
Expiration Date
TRENCH PERMIT
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et scq.(as amended)
THIS PERMIT MUS�TIBE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant i`r>t L,-w C..G ' 4t ruction
Phone Cell
Street Address 15--t omki_a pi h8- YAS-- gga�
City/Town 1 MA ZIP
Mtv,q bvul MiRO pe. UCi
Name of Excavator(if different from applicant) Phone Cell
Street Address
City/Town MA ZIP '
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Name of Owner(s)of Property Phone Cell
�J �c�c,rict �c�u�t a�� SS-77� — 17085
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Street Address M
ti Mme.r'e,
City/TownMA ZIP
LA-112A -ntlh1144 oacah3
Other Contact I Permit Fee Received No( ) Yes( ) J
Description,location and purpose of proposed trench: .0.2.1444.,(20.4rat c�'wd Ifni
Please describe the exact location of the proposed trench and its purpose(include a description of what i (or is intended)to
be laid in proposed trench(eg; pipes/cable lines etc..)Please use reverse side if additional space is needed.
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,u,„ bat IL yeti utitid, eat /)ttessa,t� '/'not c- duty r
Insurance Certificate#: c PA- 00v Wee 33C)
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Name and Contact Information of Insurer:
attlita.gd- Of12.4Wkil taiikab 5053--nc-it o
Policy Expiration Date: PIIXn.r.Q, n, a0)®9 b
Dig Safe#: ao(5#39,6 /vr)0 'C the „cis-
Name of Competent Person(as defined�by 520 CMR 7.02):
. r -11C.t-li SR-CXIC-Y/�-Y
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Mas: _nuseh!Hoisting License tt / 3(6„ i oa yhy/ao
License Grade: a ' ` Expiration Date:
BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AM) 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'OSHX REGULATIONS,
G.L. c. 82A, 520 CMR 7.00 et seq., 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 THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH
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 UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE
CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS GOVERING SUCH WORK.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AM)EXPENSES INCURRED BY TILE
MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE 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, OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDEMNIFY,AM) 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 TILS PERMIT.
APPLICAN :1G • RE
CiEXCDATE Ask-
EXCAVATOR
AVATOR IGNA'rURF 1 DIFFERENT)
• TE 7 4 /E-
OWNER'S
/P'
OVVNE�TURF(IF DIFFERENT)
DATE: ..C:\14...C:\14.1 1,\ ' '
For City/Town use—Do not write id Mb section.",. .. .. ,
PERMIT APPROVED Bis ?. • $_ • APPlie tion Fee ' ff
PERMITIJNG AUTHORITY Date' 4 ., ,
CONDTTIONS OY APPROVAL,;,, . :..., .,
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