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HomeMy WebLinkAboutTR-19-934 1. ort YAR TOWN OF 1'ARMIOF'TFi �j� �� /9�� ` t.�O BUILDING DEPARTMENT Permit NU •�oi ) 1146 Route 28, South Yarmouth. NIA 02664 \� ..... -- 5 )8-393-2231 ext. 261 Fax 508-393-0336 Date Issued Expiration Date 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 Name of Applicant ri i Fs 63 crTht?A 0.014 `— Phone Cell Street Address a3 1E ter/b-e_ nil S 3'a- 69 -3) City/f own MA ZIP dAw)me 2 (r)- /t:S Name of Excavator(if different from applicant) Phone Cell Street Address City/Town MA I ZIP Name of Owner(s)of Property MgnC , Ohisitr Phone Cell Street Address 'I S CI n'i-p l c4- not/ City/Town MA I ZIP C Wgrinai pair ir I Pall 7J Other Contact 1 Permit Fee Received No( ) Yes( ) Description,location and purpose of proposed trench: Please describe the exact location of the proposed trench and its purpose(include a description of what is(or is intended)to be laid in proposed trench(eg;pipes/able lines etc..)Please use reverse side if additional space is needed. () SepJ-.r Seg — i AUG 16 2018 ! ; _ t ! Insurance Certificate ft: W�SC° SC ��O� 0 -i L��. �EPAki'Fn -i- i Name and Contact Information of Insurer. v AS-Sec1/4C '0Y`6 Wil.SI. nint�L_CPJ - - Policy Expiration Date: b1./Q3 moi 8 Dig Safe ft: 9 Q I g ^6 , . 3200 Name of Competent Person(as defined by 520 CMR 7.02): LQV_ jihg 1 of 2 Massachusetts Bastin License/ y -.ag aki, i,tens 0130 I) 6d 1E—ofl6 73 License Grade: 1}E -2/9 C .fi••t.-" 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, CL c. 824, 520 CMR 7.00 et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND REGULATIONS AND THEY COVENANT AND AGREE TRAY 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 RECITATIONS 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 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 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 SIG DATE 7 — ( I— 17 EXCAVATOR SIGNATURE tIF D REND DATE OWNER'S SIGNATURE OF DIFFERENT) I gatoattiO DATE: • • Far t'itt/f+nrw we—D•nut write ht this reeds PIJLMITAPM%EDBY f Application IPS ' PIAMMI%C AUTHORITY Ihre IT►\DITH1%%OFAPPROW'AL - • • • 2 of 2 commonwealth oof Mu csetts • .�: Dent f PblicsaSafety License: HE-028673 Hoisting Engineer LAURENCE F ELK JR .. • I 8 NORTH ST ,trrrl DENNISPORT MA 02639 it1..e • „,Y�r E Mati&O Z74 - Expiration: Commissioner 12130@018 Hoisting Engineer • Restricted to: HE-2A-Excavators • DIG SAFE Call Center.(888)344-7233 In case of accident can:(608)820-1444 DPS Licensing information visit:ININW.MASS.GOWDPS `. L, • f From:Central Fax Fax:(677)816-2156 To: ...Fax: (508)362-6268 Page 2 of 2 12/1512017 222 PM • REIDS.LA-01 THORNE 4 -A L CERTIFICATE OF LIABILITY INSURANCE °12/15/2017' ' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcyQes)musthave ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the polity,Certain policies may require an endorsement A statement on this certificate does not confer lights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME. Rogers&Gray Insurance Agency,Inc. PHONE FAX 434 Rte 134 (AIC,No,Erb: (ac,Ne):(877)816-2156 South Dennis,MA 02660 nto4iss.mailRirogersgray.com INSURER(S)AFFORDING COVERAGE NAICS - INSURERA:EXCeISIOrInsurance Company 11045 INSURED INSURERS:Arbella Protection Insurance Company,Inc. 41360 Raid&Laurence Ellis dba Ellis Brothers Construction INSURERC:Associated Employers Insurance Company 11104 23 Enterprise Rd,P.O.Box 59 INSURER O: Yarmouthport,MA 02675 INSURER E: INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: . THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORME POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT waif RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDLSLBR POLICY NUMBER POUCY EFF POLICY EXP LIMITS INSD WVD (MMIDDIYYYYI (MMIDDIYI'WL A X COMMERCIAL GENERAL UAMUT( 1,000,000 CLAIMS-MADE ❑X OCCUR CBP9697130 03101/2017 0310112018 EACH OCCURRENCE _ t DAMAGE jO RENTED 100,O PREIelGF IE9otturrence) S MED EXP(Any one penin) S 5,000 PERSONAL a ADV INJURY _S 1,000,000 GENT.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE f 2'000'000 4 POLICY D & p RO Lot PDUCTS-COMPIOP AGG S . 2,000,000 OTHER: S B AUrOMOBILEUABILT' comma)SINGLE MOT (Eel eaelelq ANY ALTO 102000260706 06109/2017 06109/2018 Homy IN,IRYrpm pence) f 250,000 OWNEDAUTOS NLY X LA.1U�IQSULED BODILY INJURY(Pwacciamlq S 500,000 X PAM ONLY X AUTOSOtaLY 1�e0era0TetrAGE f 100,000 S _ UMBRELLA LIAB OCCUR EACH OCCURRENCE _S _ EXCESS UAB CLAUS-MADE AGGREGATE _ f DEO RETENTIONS s C WORKERS COMPENSATION I PER OTH- AND EMPLOYERS'UABILITV YINSTATUTE I TER ANY PR OPRIETORIPanNFR1E]4=QmVE WCC50050007062GI7A 12/03/2017 12/03)2019 E1.EACH ALutKNT f 100,000 p(Mparr�RIM�nNk) XCLUOEO'!, E.L.DISEASE-EA EMPLOYEE S IIAanEatoryln NH) • NIA 100,000 Ilyyoa.Eascrbe nn& 500,000 DESCRIPTION OF OPERAtiONS below EL.DISEASEPOLICYUNIT 5 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD tatISeagate;on:a Remarks Scaedmay be attached If more apace Is required) Certificate holder is an additional insured under General liability for on-going operations when required by written contract or agreement CERTIFICATE HOLDER . CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1148 Route 28 ACCORDANCE WITH THE POLICY PROVISIONS South Yarmouth,MA 02684 AUTHORIZED REPRESENTATIVE iC )r-Hotocel ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. • The ACORD name and logo are registered marks of ACORD