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HomeMy WebLinkAboutBLDTR-19-001160 TOWN OF YARMOUTH &D7�e- /9-oo //&o / af YgRyo BUILDING DEPARTMENT Permit Number H Lt., 1146 Route 28,South Yarmouth, MA 02664 � 508-398.2231 ext. 1261 Fax 508-398-0836 Date Issued Expiration Date $50.00 TRENCH PERMIT Pursuant to G.L. c. 32A §1 and 520 CMR 7.00 et seq.(as amended) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Naar of Applicant RC,c. 9esz_, ti_ .!ss. Pr'g aS- SieU Street Addreos ?al 2c t .544r—szn-oeroa City/Town MA ZIP c v-eZ (L b`36 Site Nan of Excavator lif different from applicant) Pr CeU Street Address City/Town NA ZIP None of Owners)of Pnperty. (cc1/4".Zit'clr� s Phone Cell(0C/ ZS Street Address — :bast V).W& -t '% w c- ( s,7.-a9v-9cn City/Town MA ZIP 4,r-vg3c.ANicz✓ 0i-lei Other Contact i Permit Fee Received No( ) Yes(4' Description,location and purpose of proposed trench: Please describe the exact location of the proposed trench and its purpose(include s description of what is(or is intended)to be laid In proposed trench(et;pipes/cable lines etc-Irian use mine side Iff additional!pace to needed. ---S:\ J-O�' eel ti l �7 t 4 w W..O C.- 1/4....) (� =l-....,.t4\, v.,eco � ec ' c. S�.SvG`t.r. Io... 4'�+"aw�. Insurance Certificate Of L2- S - 3 l 3tcb Nan*and Contact Information of Insurer: LIt' - - c` ,4 (, e. e. --_..--- 'ci3c ,-4 oZo "7 Wictiewet ,t 7�l 03£ 3(-a©Q Polley Fepintlon Date Y( !S ( 610(9 -•- 1 1 DIN safe M: ;0(,-3L.-IOC??g7 Name of Competent Perron las defined by 524 CMR l.V1t: 5?n---S.4V—acZ! SCJ C'kX--` I of 2 • f'. • Musxhusetts Hoisting License 11.1 \Yric3 Fr • Lkense Grader 'A \C. Expiration Date: ( � l Ct 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, G.L. e. 82A, 521 CMR 7.01 et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND REGL7.ATIONS 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 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 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 OP STATIC 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 SIGNATURE �f DATE Fr.?7j/g' EXCAVATOR SIGNATURE IIF DIFFERENT) DATE OWNS'j. SIGNATURE(IF DIFFE ,/A — — — DATE: Far CR1fowii aar–Da aa;Eta S Sb mut An*WW ICY ApplicationFn REAUtn iwj A Dor CO=AL • 2 oft