HomeMy WebLinkAboutBLDTR-19-001066 of Yqe TOWN OF YARMOUTH /��
I e-' � 'So BUILDING DEPARTMENT Permit Num-
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'l a c 1146 Route 28,South Yarmouth,MA 02664 �'—
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..,-I„S. 4” 508-398-2231 ext. 1261 Fax 508.398-0836 Date Issued
Expiration Date .
$50.00
TRENCH PERMIT
Pursuant to G.L.c. 82A 31 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
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Naar of Applicant R,`1_(3Qt rl. (3zoiz. CO Phone Cell
Street Addree SC) .-* 93a- 0530
au ere'T itats-serN psi.
City/Town I MA;�2W1� 7 I
ZIP
H03L 95'
Nan of xeaeator of diferent,.T om applicant) Phone CeU
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Street Address
' 1 r 7 A 1-e trGe. 71)17- g3G-' crn
City/Town MA ZIP
S 4 au_Ac.AA, IMS 0 a-5103
Name of Ownerist of Property Phare Cell
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Street Addras 'was Met Cf .I
I L MfrrolbA Re) G1/1-915-- °99
chyRown 1 MA I ZIP
Other Contact i Permit Fee Received No( ) Yes t 1
Description,location and purpose of proposed trench[
Please describe the exact location of the proposed trench sad its purpose(Include a descriptias at what Is(or is intended)to
be laid in proposedostrench(et;pipes/cable lines mime etc..)Please use e side it additional
gr Curved Hive Rdspace t needed.� Ce�r sit?e of o�Se, [Soo
gctLo,J 5kiii,c V-bO )�3\ SOO cJ/LON CIO)
Insurance Certilkata Ms
i CPA Name and Contact Information of insurerseo t L�a �� n
• I4Uf\ z 1 t A )ciSiOA)9,1 NP,43 Ct``AArCY
Policy Fxpintian then V _
DIB Safe It
fin► )6 -3'O-3113°1
Name of Competent Person In defined by 520 IL MR 1.021
Ian ti 1� t-e, �� rer,Pe�`P, —
;f!_-Cis: _J I= D
AUG 22 2018
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Mwchusette Heisting Ilene I K 0 aG33
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Limn*Grades Expiration Dates S I 16V
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,
C.L e. EA. 529 CMR 7.09 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 WT'H THE CONDITIONS SET FORTH
BELOW.
THE UNDERSIGNED OWNER AUTHORIZES TILE APPLICANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO, FOR THE
DURATION OP CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT TTIE WORK FOR CONFORMITY WITH THE
CONDITONS 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 THE
MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDTTONS OF
TUB 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/Z
DATE glaWig"
EXCAVAT R SIGNATURE IP DIFFERENT 1
DATE c�3b`�C6
OWNERS SIGNATURE IIF DIFFERENT)
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(�APPRUYED BY Fa CB?./Tswr �j
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CONDITIONO O�U�A�
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