HomeMy WebLinkAboutBLDTR-19-001158 ,'4 ��.yqa TOWN OF YARMOUTH p
I 4'- 4 BUILDING DEPARTMENT Permit Num1Ye� -�9�OD1lS�
• p� \yg y 1146 Route 28,South Yarmouth,MA 02664
r ..,,.:1 x 508-398.2231 ext. 1261 Fax 508-398.0836 Date Issued
Expiration Date ,
$50.00
TRENCH PERMIT
Pursuant to C.L.c.82A $1 and 520 CMR 7.00 et seq.(as amended)
THIS PLR.MIT.MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
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Street go8�7aafsa5
330 O,a,lte
City/Town MA ZIP
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Street Address
City/Town I MA I ZIP
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Street Address
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Other Contact I Pertnk Pee Received No l 1 Yat )
Deerlptlon,bathsand punnet of proposed tnaebr
Pits describe the tsars location of the proposed trench and its purpose(Include•dacrtptdon of what is(oris intended)to
be laid In proposed trench(tet pipes/table Una etc.)Peas ins menus vide If additional space Is needed.
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RECEIVED
•
AUG 27 2018
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Insurance l'rrNfkay Mt '1P ()N���D_c•M, _ O.l� 7
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; Nan and Contact Information of Insurer= Oow\t n0 4r O'Nt'w Insuro r to
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Name of Competent Pianos las defined by 520(Mateo:
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(thaschise(4e Hoisting License F !1 E OS a gi'J7
46 IJcemn Grade C) a01,' expiration Duet 57. 1/ Yg
BY SIGNING TEAS FORM. THE APPLICANT, OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
TEAT THEY ARE FAMILIAR WT'H,OR,BEFORE COMMENCEMENT OF THE WORK,WILL BECOME FAMILIAR
WTTIil ALL LAWS AND REGULADONS APPLICABLE TO WORK PROPOSED.INCLUDING OSHA REGULATIONS.
GI. a 121, 5211 CMR 7.011 d x4. 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 TAE APPLICANT TO APPLY FOR THIN PERMIT AND TTI<
EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO. FOR THE
DURATION OF CONSTRUCTION, AUTHORIZES PERSONS DULY APPODYTID BY THE MUNICIPALITY TO
ENTER UPON TILE 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 EXPENSES INCURRED BY THE
MUNICIWALTY IN CONNECTION wan THIS PERMIT AND THE WORK CONDUCTED 2 NEREUNDER.
INCLUDING BUT NOT LIMITED TO ENFORCING TNR REQUIREMENTS OF STATE TAW AND CONDITIONS OP
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 TIER MUNICIPALITY. •
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDEMNIFY,AND HOLD HARMLESS THE MUMCIPALT'Y AND ALL OF T8 AGENTS AND EMPLOYEES FROM
ANY AND ALL 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 WORK
CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNA
1 �� DATE $44/6, "
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT
DATE:
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