HomeMy WebLinkAboutBLDTR-19-915 r""YaR TOWN OF YARMOUTHI
� T
's 0 BUILDING DEPARTMENT ' Permit Number RUJ �`e .{9 '0-0(6 ,�
o1 y 1146 Route 28, South Yarmouth, AIA 0266 i Date Issued508-398-2231 ext. 261 Fax 508-398-0836
=~ ` Expiration Date
TRENCH PERNIIT
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
TINS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant ar 1.0. C t_,[,oo—_ Phone Cell
Street Address li fsirxiUyatn*A 508- r?r) ( -<3919 .
City/Town MA ZIP
Mttts(vg M;lts o2-coV8 '
Name of Excavator(if different from applicant) Phone Cell .
Street Address
City/Town MA ZIP '
Name of Owner(s)of Property $,„,,,r. ,`ape ate Phone Cell
Street Address ?o%Box 5'a.S 1
City own( r MA ZIP
b-kw/NilYcr,A' 0a4 '76—
Other Contact Permit Fee Received No( ) Yes
Description,location and purpose of proposed trench: -5.0-id. - kc it - 6"Carrfe{Ci
Please describe the exact location of the proposed trench and its purpose(include a desc 'lotion of what is or is intended)to
be laid in proposed trench(eg;pipes/cable lines etc..)Please use reverse side if additional space is needed.
^-atw,14, c.) S 9a-&p la 4em k, t¢ao &co!-u,de,&n/.�A., 341 x so'unAkins evum.
('1-
I 1 (- 4ArJvtQ-f QLUnfle•f�,tAt1 4n Ric44
11
d IRECEIV' E)
Insurance Certificate#: QPA Oo8/468330
I AUG 15 2018
Ra4-0a9oSo)-3 1 aui_ui_l t '13
Name and Contact Information of Insurer: / L
De (— Onej( .uAt ._ SoEs--),6 /Gac)
Policy Expiration Date: / !), a-OI C/
Dig Safe#: atm /330 5Zo'75 S' I in his, v.3O
Name of Competent Person(as defined by 520 CMR 7.02):
1 of 2
1 `
Mas: liusetts Hoisting License# 3(.¢ (,U y it y l ao
License Grade: `L A Expiration Date:
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 APPL£CABLE'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 THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR
SUCH WORK WILL COMPLY THEREWITH N 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 COVERING SUCH WORK.
TEE 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 CONDITIONS OF
THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES TAKEN BY 1 H
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 TEE 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 SIG ``��
DATE 47Pthr
EXCA OR SI (IF DIFFERENT) /
DATE 8v/d
OWNER'S SIGNATURE(IF DIFFERENT)
- DATE: IA/ \trr
. - . For City/Town use—Do not write id Mit sectiaa• •-•
PERMIT APPROVED BY a . . . . • S. • :•App&icateon Fee
PERIefIT LING AUTHORITY IPatE' ;. .. -
CO.NDTIYONS OF APPROVAL,
2 of 2