HomeMy WebLinkAboutBLDTR-19-001093 f;1' 01YaR TOWN OF YARMOUTH 3{,(�j-(-e,-1C- _Do (pq
it � s ',BUILDING DEPARTMENT Permit Number 3
p .fei,i y 1146 Route 28,South Yarmouth,MA 02664
E' .^I 44 508-398.2231 ext. 1261 Fax 508-398-0836 Date Issued
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Expiration Date .
$50.00
TRENCH PERMIT
Pursuant to G.L.c.82A Il and 520 CMR 7.00 et seq.(as amended)
THLS PERMIT MUST BERVLLY COMPLETED PRIOR TO CONSIDERATION
Nan d Applkant Cell
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Street Addtesr
250 CMtM.
City/Town MAIZIP
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Name of Excavator(if different from app&aM) Plow Cel
Street Address
City/Tewn IMA 1ZW
NowofOwnnlqofProperty Pham Cell
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Street Address
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Other Contact I Permit Fee Recited No( ) Yes( )
Description,tondos and purpose of proposed trench
bePlease describe the exact location of Use proposed trench and Its purpose(Include a dacriptlea of what is(or is Intended)s
Proposed trench left pipalesbk lines etc-)Please use resent aide If additions apace Is needed.
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• RECEIVED
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. Insurance Certificate t �i � � 'U ,
ate pl �'P )!�J `CSi�(3Q'AQgi� GUILIN N UUEPAR IMbN 1
i NUM sad Contact Informed m ofInsurer I e ,,At n By
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Po Oat 1440 1-lyonns clic (lato0l
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1 ,Nine of Competent Penes in defined by 320 CMR 1.0:i;
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• Limit Grade C., act,JR Expiration Dart /9
BY SIGNING Tins FORM. THE APPLICANT.OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
TEAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF THE WORK,WILL BECOME FAMILIAR
( ALLAND REGULATIONS APPIORDREGULATIONS.
BetAND ANY MUNICWA! ORDINANCES. LAND
REGULATIONS AND THEY COVENANT AND ACRES THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR
SUCH WORE WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDFElONS SET FORTH
BELOW.
Tilt UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WORE ON THE PROPERTY OF THE OWNER. AND ALSO, FOR THE
DURATION OF CONSTTWCITON. 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 WORE.
THE UNDERSIGNED APPLICANT.OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND K PEIN.SES INCURRED BY THE
MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING RUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF
THIS PERMIT.INSPECTIONS MADE TO ASSURE COMPLIANCE THP.RSWith,AND MEASURES TAKEN BY THE
MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAH.ED TO
COMPLY T HEREWITH INCLUDING POLICE DETAILS AHD OTHER REMEDIAL.MEASURES DEEMED
NECESSARY SY THE MUNICIPALITY.
TEE UNDERSIGNED APPLICANT.OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
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INDEMNIFY.AND HOW HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYES FROM
ANY AND ATI.LIABILITY.CAUSES OR ACTION,COSTS.AND EXPENSES RESULTING FROM OR ARISING OUT
• OP ANY INJURY. DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORE
CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNA
�� DATE 4.6P4 z4
EXCAVATOR SIGNATURE OF DIFFERENT)
DATE
OWNER'S SIGNATURE IIF DIFFERENT)
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lit . .., ,. ., ,. I DATE:
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