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HomeMy WebLinkAboutBLDTR-19-001416 1612:rTOWN OF YARMOUTH ' aansig �p BUILDING DEPARTMENT Permit Number &Ub72-4- �il4, o; hit 11.16 Route 28. South Yarmouth. MA 02664 �', .... i •v'= 508-398-2231 est. 261 Fax 508-378-0836 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 '_I is (3,,,,i_ed GPO- Phone Cell Street Address a3 I'mtra)(Se ) 5E- 362- ‘;3) City/Town MA ZIP o -eiS Name of Excavator if different from applicant) Phone Cell Street Address City/Town MA ZIP Name of Owners)of PropertynPhone Cell HJT Street Address n J 66e C9i-i4 eIhtt � (%) sc8- SGaic Citylrown A I ZIP /~ , ,<0- I oa475 Cher Contact I 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(eg;pipes/cabk lines etc..)Please use reverse side if additional space Is needed. 11 AL' rr-RECE1v �1 r 10 2D1% SEP .. R �„T t gVILDtNG l____-- RV Insurance Certificate 0: WCC so a SOCSOO 76 I Name and Contact Information of t—'Insurer:r 1 Pi SaCtMM-QJ f t)SA4rci co 1 Policy Expiration Date: ',?)')ir ` iDig Sate II: act &- 3cI 3is' 1 Name of Competent Person tas defined by 520 CMR 7.02): Obt ntj r((tf 1 oft j • Massachusetts Hoisting Licenser 14. E.- o a -C73 id /8o/ If License Grade 1+(; -Ci- Exc4 iicl-dS _Expiration Date•. 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. 81A, 520 CMR 7.00 et 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 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 TC) ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE CONDTITONS 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 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 SIGNATURE DATE ` T EXCAVATOR SLabi IIF DIFFERENT) IA.. __. •. —.•D a S DATE Si OWNER'S SIGNATURE(IF D t RENT) DATE: Far lih/Invn re..Ds not write Ea Air arctIfln PF7L�1I7'APP.0.1,n B1 ( St : AppBenllanEn. PEIL11rm\G AUTHORITY Date !' i CONDITIO\SIOFAPPROVAL • .. f 2 of 2 - • .• Commonwealth of Massachusetts ®: Department of Public Safety • License: HE-028673 Hoisting Engineer LAURENCE F ELLS JR DENPORT MA 0289 ic- / � Y / j ers �1itaa Expiration: /Commissioner 12130/2018 "-Hoisting Engineer Restricted to: • HE-2A-Excavators DIG SAFE Call Center,(888)344-7233 In case of accident call:(508)820.1444 DPS Licensing information visit W WW MASS.GOV/DPS �. Front Central Fax Fax:(888)507-0822 To: . .Fax: (508)362-8288 Page 2 of 2 06/042018 1:12 PM „�� REIDB.LA-01 AMAHLER A`ORLY CERTIFICATE OF LIABILITY INSURANCE DAoefoa2018 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 s....REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(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 suchCCp e�Tnrpdorsement(s). PRODUCER NAME:CT Rogers 8 Gray Insurance Agency,Inc, PHONE 414 Rte 134 WC,Ns,Est): Est): I W c,'4*(877)816-2156 South Dennis,MA 02660 k miss.mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC I INSURER A:West American Insurance Corn pany 44393 INSURED NSIRERB:Arbella Protection Insurance Company,Inc. 41360 Reid&Laurence Ellis dba Ellis Brothers Construction INSURER:Associated Employers Insurance Company 11104 21 Enterprise Rd,P.O.Box 59 NSURERD: Yarmouthport,MA 02675 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER; THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELON HAVE BEEN ISSUED TOTHE 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 SUBJECTTOALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.ILLIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE IF 9y p POLICY NUMBER (MMib�DIYYFYY) (MM/DOTTTLICY YYY) LIMITS A X COMMERCIAL GENERAL LIABILITYEACH OCCURRENCE S .1,000,000 CLAIMS-MACE ❑X OCCUR BIC/V(19)58371201 03)01)2018 03/0112019 DAMAGETORENTED 100,000 PRPMISFs(Eeorcu0encet t 15,000 MED EXP(Any onepoiscn) S — PERSONAL A ADV INJURY _t 1.000'000 GENT.AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICYnT ❑Loc PRo011CTS.COMP/OP AGG s 2,000,000 OTHER: t B AUTOMOBILE untiTY (COM&pEDSINGLE UNIT t ANY AUTO _ 1020002607 06 06)0912017 06)0912018 BOORT INJURY(Per poison) S 250,000 — OWNED SCHEWLED SOO,OOH' �ApUWS ONLY X AAUUTTOpSW E ppBOOROLY INJURY IPereccNana S X AUTOS ONLY X AUTOSONNIB tPNPPronl)AMAGE t 100,00 S _ UMBRELLA LIAB — OCCUR EACH OCCURRENCE _ t _ EXCESS UAB O.AMSMACE AGGREGATE t DEO RETENTION S s C WORKERS COMPENSATION - R FP- AND H- ANDEMPLOYERS'LIABILITY ATVTE E ANY PROAPAREIETBOERqiPARTNfF/F>a-CUTIVE Y(SNI WCC50050007062017A 12103/2017 12/03/2018 E L.EACH ACCIDENT t . 100.000 ` Pigs:ryInNMEXCLUDE i I N)A 100,000 IIIIyes.describe ower E L.DISEASE•EA EMPLOYEE t DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT S 500.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORO tot Additional Remarks Schedule,may b attached amore space Is r.Rukod) Certificate holder is an additional insured under General Liabiity for ongoing operations when required by written contract or agreement. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Tom ofRoYamte ACCORDANCE WITH THE POLICY PROVISIONS. 1146South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE I �,NS SE [,7 —_ ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD