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Home My WebLink AboutBLDTR-19-001414 ter og•YgR TOWN OF YARMOUTH r ' \o BUILDING DEPARTMENT PerfnitNumbete3U572/7-019/Y ( :Jana ryi 1146 Route 28. South Yarmouth. MA 02664 .F,'\. 508-398-2231 ext. 261 Fax 508-398-0836 Date Issued • Expiration Date TRENCH PERMIT Pursuant to G.L.c.82A §1 and 520 CMR 7.00 et seq.(as amended) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant lyti %S eitzo.ed CO'tvbt-- Phone Cell Street Address a3 13444.7-015.24_far/ S?-�$" 6� 1-a 3 7 City/fotrn� M. ZIP s- ,Thczpi Name of Excavator(if ifferent from applicant) Phone Cell Street Address City/fown MA ZIP Name of Ownerls)of Property n Phone Cell Street Address -3S r/)-p,el,Ren 51V Sed- 351- 3a51-264- y31-7Lf 7) City/Town {�G� MA ! ZIP 04.25 / rtnc'1"�y�'1 / II } (her Contact I Perndt 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 descrihat or is intended)to be laid In proposed trench� leg:pipes/cable lines etc..)Please use reverse sidci q((yyrr�a riEed . n'aid So1"t—SyYlal LTJ_ SEP 10 41 d ke 0, eln • •TME 8y -- Insurance Certificate ti:uv c^S0 S�� -206>/7 Name and Contact Information of`Insurer. : Policy Expiration Date: 1 Sr 0: aDig Safe e 1 as I et() cie t Name of Competent Person las defined by 520 CMR 7.020 1 of 2 . y r Massadimetts Mating Lkense _ \ 11 — 6a 5473 6414 \a Lienee Grade: if q-a O ikx.G°1'Vr 'W Expiration Date. BY SIGNING THIS FORM.THE APPLICANT,OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT THEY ARE FAMILIAR WIn?,OR,BEFORE COMMENCEMENT OF THE WORK.WILL BECOME FAMILIAR WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS, GL c. 82A, 520 CMR 7.00 N 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 WITH THE CONDITIONS SEP 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 It) 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 LI MIED TO ENFORCING THE REQUIREMENTS OF STATE 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 SIGN ' dp /At . A _A • DATE EXCAVATOR SIGNATURE(IF D i r 'RENT) DATE • WNER'S SIGNATURE� (IF DIFFERENT) 1 V.•Q(PVen - DATE: e (Z 1 a Far t9Mlaen we-Di net write is WI seeds PERMIT APPROAF.DSt S. AppBatiesFee - rEIL%HITTING AUTHORITY Ike CDSIUfflO%NOFAPPRIIY'AL - - - • 2 oft Frons:Central Fax Fax:(888)507-0822 To: - .Fax: (508)382.8288 Page 2 of 2 0810420181:32 PM , REIDBLA-01 AMAHLER zA`CPRoa CERTIFICATE OF LIABILITY INSURANCE DATE 6/0420 8 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES , BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED n. REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: N the certificate holder Is an ADDITIONAL INSURED,the pollry(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such eenndarsement(s). PRODUCER E2Li :per Rogers&Gray Insurance Agency,Inc. 434 Rte 134 WCNN o,Exq: I Vdc,No):(677)816-2156 South Dennis,MA 02660 kticass:mall(IDrogersgray.com INSURER(S)AFFORDING COVERAGE NAIC NSU2ERA:West American Insurance Company 44393 INSURED INSURER B:Arbon Protection Insurance Company,Inc. 41360 Reid&Laurence Ellis dba Ellis Brothers Construction INSURER c:Associated Employers Insurance Company 11104 23 Enterprise Rd,P.O.Box 59 INSURER D: Yarmouthpart,MA 02675 Fauns : NSURERF: _ COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSO nyd POUCY NUMBER POLICY EFF MIDO ESP LIMITS (MOLICYEFF -(POLICVEXY) A X COMMERCIAL GENERAL UABILIT/ EACH OCCURRENCE f 1,000,000 CLAIMS-MADE EX OCCUR BKW(19)58371201 03/01/2018 03/012019 PR(MSES Eaocro°nca) s 100 60 MED EXP(Any one person) t 15,000 PERSONAL 6 ADV INJURY f 1,000,000 GERI AGGREGATELIMIT APPLIES PER GENERAL AGGREGATE S 2,000,006 n &POLICYn1OC PRODUCTS-COMPIOPAGG S 2.000,000 I OTHER: f B AUTOMOBILE LIABILITY CO idem) NGLE LIMIT _p ANY AUTO _ DU 1020002607 06 08/0912017 067092018 BODILY INJURY(Pet person) f 250,000 �AUpT�O�S ONLY X AUOoT��,I1OppSWWL��E��D pBpORDILY INJURY(Per accident) f 500,000 X AUTOS ONLY X AUTJSONLV (Pe°aPER 9IAMAGE S 100,000 f _ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE f _ EXCESS LIAB CLAIMS-MACE AGGREGATE S DED RETENTIONS p� I 1 p7 f C WORKERS COMPENSATION I STATUTE I H. AND EMPLOYERS'LIABILITY Y IN WCC50050007062017A 12/03/2017 12/032018 100,000 ANT(PRRpp�PRIIETBOEPoPARTNER7ECUTIVE E L.EACH ACCIDENT f (M ntlstory In NH)EXCLUCEDY NIA EL.DISEASE-EA EMPLOYEE f 100,000 ny es,aescrlae onaer 500,000 DESORIPTIONOFOPERAT1ONSaemv EU..MSEASE-POLICY UMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORO 101 Additional RemwMs Schedule,may be attached If more apace la required) Certificate holder is an additional insured under General Liability for on-going operations when required by written contract or agreement. • • CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE Tavel of Yarmouth TIE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1146 Route ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE • ACORD 25(2016103) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts P.®.' Department of Public Safety License:HE-028673 Hoisting Engineer :, t N i LAURENCE F ELLS JR 8NORTH ST - -. z _ DENNISPORT MA 02839 I ' r Expiration: /Commissioner 12/3012018 • Hoisting Engineer Restricted to: • HE-2A-Excavators DIG SAFE Cao Center:(888)3447233 hi case of accident call:(508)820-1444 DPS Licensing information visit:W W W MASS.GOV/DPS �.