HomeMy WebLinkAboutBLDTR-19-000916 aR . TOWN OF YARMOUTH
„,se. o BUILDING DEPARTMENT i Permit Number&172.-lG -( C I
p —� y 1146 Route 28, South Yarmouth, (•L4 02664
Y — .�T 508-398 -2231 ext. 261 Fax 508-398-0836 Date Issued
Expiration Date
TRENCH PERMIT
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
TEILS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of ApplicantLr4 a f T C Phone Cell
Street Address pa•nex Toy 563 "9/ 4379
City/Town MA ZIP
tMAitn ru nq AR I U S 0'-c-•4 &
Name of Excavator(if different from applicant) Phone Cell
Street Address
City/Town M'A' ZIP
Name of Owner(s)of Property' 9 Sur', (j0 4 Phone Cell
ent41 Cu- 4 Cs 3c, 8
Street ddress /6" e-ftft,4.4.
Citylr MA ZIP
horn 0/ -7,70
Other Contact Pert Fee Received �No'.(^). Yes(
Description,location and purpose of proposed trench: (I 4 Ke,1 C ei_p.cDr. (cae-� ,
Please describe the exact location of the proposed trenc and its purpose(include a desc 'ption of what is(or is intended)to
be laid in pro ed trench(eg; pipes/cable l
iipes/cabbllelines etc..)Please use reverse
side if additional space k needed.
' -~ V/" l/cys/zee Avearcya, ienunozM4i , ('
t0
Dzsciaubleir 6o,4t 3- 0.110,5667a-0-&-4-7 /180-4-1 612471 AJ1/cw4e
tc. ckale
A-4-41
a. I a.fl'Lt.) X 33.51c x 3 ,/a ti 2 area_ Wt?I c./0 Mi/1Cb/r, Mier; C/udtn�iW 7t
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ECF: -r'
Insurance Certificate#: CPq oog 148 330
pis t ; 2018
Aawet5Stn- -, �� -'7
Name and Contact Information of Insurer: �' ,i � �-' 1 -(--
DolaoQlt.ngl- Patti SxtctuovvtAt_ SoS n/6-
Policy Expiration Date: •-{Yl&49 ') a o i4
Dig Safe it: go},3 33054,6,A 8lit /,g I :3:3 ✓/
Name of Competent Person(as defined- by 520 CMR 7.02):
I�I� L c I
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ores: .oasetts Hoisting License# /3(, yo.)... v
yla
License Grade: a 4 _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 APPLICABLE 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 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 COVERING SUCH WORK.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY TEE
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, 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.
APPLIC SIG • TURE
DATE 4/97(r-
Orr
IY/lr
'•T CAVATOR SIGNATURE OF DIFFERENT)
DATE (aI iu i 25
OWNER'S SIGNATU^ (IF D II RENT)
. /..• Y�1L/,l ' ATE: 3/018
. For Ott/Town use—Do not write id this herdic,
PERMTF.APPROVE.B t4 > . . . . ., .., _. A�inBectatann E ee
PERIaITIIINC.AUTHORITY . DaC&";,
CONNDTTIONSOF-'APPROVAL: •, :?'. .
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