Loading...
HomeMy WebLinkAboutBLDTR-19-001071 .o1'T 4,te TOWN OF YARMOUTH jLS1R��q-wio �' ,.fir e BUILDING DEPARTMENT • Permit Number ` OI T 11.6 Route 28. South Yarmouth, MA 02664 � .,,,,;, ia S08-398-2231 ext.1261 Fax 503-398-0836 Date Issued • Expiration Date $50.00 • TRENCH PERMIT • Pursuant to G.L.c;82A §land 520 CMR 7.00 et seq.(as amended) • THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of ApplidM/I t � p►�� f Phone NameofAPPa (.:� fret Cell IJGut4ttrv{ Rd • ' 8 �98. '�{10 0$ 39� -10 0 C' /town• `r,((4�'��, I MA I ZIP • Name of VL( ret' or Of differpA from applicant/��J p, U2blld�{Q Cl, Phone •Cell Street Add 61,Li .� •.5 vO • 989 - ga7 ‘51 - t'fi61i 44,&6 ' . Cin MA. [ZIP . . nekto Name of Owitems a f Pm 01/51 ry ) Perty .p • 7 Pbone GCLII jU-14 A-• Cell Street Address n 015 9ad<ers� Ori . CleyiTown S I MA I ZIP Other Contact J 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(est plpesieabk lines etc..)Please use rerene•dde If additional space Is needed. :.-g% �;-- '�r RECEIVED! o (,�4, • • re- AUG 22 2018 I I BUILDING DEPARTMENT By: 1 Insurance Certificate M: _+ Vane and Contact Information of i Insurer, Po-ers and 67 0 • Suta t>R.e.. 5'b$. •39$••'191 - : Policy Expiration Data Dat Dig Sa a lh .5" 10 191 j y-. 01-6 ita -• 390 . 4451 Name of ompelept Person I • ned by S20 CMR 7.02): r • . 1.of2 • AL.A.schasetaRagtag Lemmas E{M©�-fer • VIT77-0 9 License Grade r G-a-/3- • } • aIs • atton Este: ' t BY SIGNING THAT FORM,TOR ASPLICA.1 , OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND TREY ARE FAMILIAR.W OR;BEFORE COMMiL OF TBE WO wan,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLODIN OSBECOMEHA,RE LIAR G.L. c. S2A, 520 CMR 7.00 et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND REGULATIONS AND THEY COVENANT AND AGREE TBATALL WORK DONE UNDER TiUE•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 TEE EMU/AMR TO UNDERTAKE SUCS WORE ON TME PROPERTY OF THE..OWNER, AND ALSO, FOR TUE DURATION OF CONSTRUCTION; AUTHOBTZES PERSONS DOZY AYPOIIVT$D BY THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONI•POR AND INSPECT TBE WORE FOR CONFORMITY WITH THE CONDITIONS ATrACB ED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH WORK. THTHE tNDERSICNIED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO REWIBU'AETY1N UNIaECTA[ON FOR ANY AND ALL COSTS AND EEPENSESTNCURREDBYTHE INCLUDING BUT NOT WITH TMS PERMIT AND THE WORK CONDUCTED THEREENDER, TRIS B,INSPECTIONS MADE ENFORCINGO THE REQUIREb1ENTS OF STATE LAW AND CONDITIONS OF TRIS PE i ,INS PROTECT THE PUBLICASSURE COMPLIANCE ,AND MEASURES TAKEN BY THE COMPLYTBEREWTTHINCLUDIN POLICE DETAILS D�O OR EXCAVATOR HAS FAILED TO NECESSARY BY TBE MUNICIPALITY �. REnEEDIAL M>�ASURES DEEMED • THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND, ANY AND ALL LIABILITY,noj Iy�THE MUNICIPALTIT AND ALL OF ITS AGENTS AND EMPLOYEES FROM OF ANY ALL LIA DEATH, USES OR ACTION,COSTS,AND EXPENSES RESULTING FROM OR MUSING OUT CONDUCTED UNDER IBIS PERMIT.LOSS, DAMhGg TO ANY PERSON OR PROPERLY DURING T86 WORK • • APPLICANT SIGNATURE • ,. , . n— _I DATE Y7 1$ ' • B►'CAVATOR SIGNATURE(TIT EFFERENT) Qr / i fr/� _ DATE �/ �f O •,S SIGNATURE(IF DThnREN: 1 '•DATE: it)(9 J • P�iiITAPlrROVED B Foe eitv/Iinaage—DO not write Intl swam . PERMITTING Amami . ;r.,—:A a Irec. CONnmONS Odi APPROVAL:. . .. �, • • • 2o12 ` . • k•