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HomeMy WebLinkAboutBLDTR-19-001415 } '"woe YqR TOWN OF l'ARMIOI'TH t�rfl �G lya % r ) a BUILDING DEPARTMENT ie Permit Number E .l31 1�— Lill0 r//1 �y 1146 Route 23, South 1'anuouth. MA 02664 \.-Y I' f�Z' 508-398-2231.ext. 261 Far 508-393-0836% 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 aI 6 is 63 rbi,)hoC C *ttPhone Cell Street Address 0_ 3 13� �j,rf c t l p -n5 -3 & a & ? Cityfrown (! MA ZIP Pd�0.941.1�( J dti_ Na of Excavator( different from applicant) Phone Cell Street Address City/Town MA I ZIP Name of Owants)of Property 1a V a 11.ty4. krrp ,j Phone Cell Street Address SL+ S ct l l 1 t2aiwl Y' 1 o \CC* o - g—q - 43 7 City/Town MA I ZIP Vest--* ^ I 0)-( 7-5 Other 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;piper/cable lines etc..)Please use reverse side if additional space is needed. Iwo Sep}lc , RECEIVED rJ� SEP 10 2018 BUILDING DEPARTMENT By Insurance Certificate 0: W C f s:500,--)e,-Q0) O./"7 t I Name and Contact Information of Insurer: ✓ 6� 1 fe S.aCik } I5./^1' t Policy Expiration Date: 16-_i �( // Dig Safe K: aoL& 330 13-8 + (83 %n I Name of Competent Person las defined by 520 CNIR 7.02): IA _ �Gj . Iof2 .tir • Matrrcbusetta Haiatiug Lkensei4f r-a ��l�j�rj�Lrs 1 al 30 I 1 fr 6 License Grade: `f�_Oa��73 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. VA, 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 TO ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE CONDMONS 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 WE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO COMPLY TTIEREWTTH 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 �j y4 X.e / DATE -V-s---11 EXCAVATOR SIGNATURE IIF D RENT) DATE O r Es'S SIGNATURE(IF DIFFERENT) • •:>.i d Ati' - DATE: / G • Far tintI.w a..De nM write Is tbk seethe- PERMIT nti.PERMIT Arno{Eniv f, APS Fre •PERMITTING A Darr lTAOTIItri%UFAI'PIt0m . 2of2 • • Commonwealth of Massachusetts ::®: Department of Public Safety License: HE-028673 Hoisting Engineer LAURENCE F ELLIS JR �i00ir 8 NORTH ST DENNISPORT MA 02839 - - � 'Nod& bet" Expiration: Commissioner 12/302076 Hoisting Engineer Restricted to: • HE-2A-Excavators • DIG SAFE Call Center.(888)344-7233 In case of accident can:(608)820-1444 DPS Licensing information visit W W W.MASS.GOV/OPS ‘. Front Central Fez Ern:(888)597-0822 To: - .Far (SO9)3624266 Page 2 of 2 66/00120181:92 PM e /.....1 REID&LA-01 AMAHLER A ORO" CERTIFICATE OF LIABILITY INSURANCE DATE owto01B 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 o. REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: N 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 tights to the certificate holder In lieu of such endorsement(s). ACT PRODUCER NAME. Rogers 8 Gray Insurance Agency,Inc. 434 Rte 134 INC No,EAT: I la4,101877)816-2158 South Dennis,MA 02660 IDOAI(iss.mall@rogersgray.com NSURER(S)AFFORDING COVERAGE NAIL e INSURER:West American Insurance Company 44393 INSURED NSURERB:Arbella Protection Insurance Company.Inc. 41360 Reid&Laurence Ellis dba Ellis Brothers Construction INSURERC:Associated Employers Insurance Company 11104 23 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 BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF MY CONTRACTOR 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 SHOVVN MAY HAVE BEEN REDUCED BY PAID CLAIMS. (LTR TYPE OF NSURANCE ArySLS POLICY NUMBER POLICYEFF POLICYEXP LJArre () {MOLIC YYYTI POLIC YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S .1.000,000 CLAIMS-MADE ri OCCUR BHW 19 58371201 03/01/2018 03/0112018 DAMAGETORENTED 100,000 ( ) PRFMIS S(Ee occurrence) t _ MED EXP(Any one person) S 16,000 _ PERSONAL/t.ADV INJURY _S 1,000,000 ' GEM AGGREGATE LIMIT.APPLIES PER GENERAL AGGREGATE S 2,000'001 )-11 POLICY ID 7CoT III IOC PRODUCTS-COMPIOP AGG S 2,000,000 OTHER: S B AUTOMOBILE LIABILITY COMBINED SINGLE UNIT - BODIL gent) S 250,000 ANY AUTO 102000260706 06/09/2017 06/0912019 &pixy INJURY porperson) t — pyyNED SCNEQSULED 500,000 IA{UpT�OpS ONLY X AUOoTµµOppWW EnlI pBp{O{RRDILY INJURY per Kama s 0. X AUTOS ONLY X AUTOSONNIP (Pae[OgnI)AMAGE t 100,00 I — UMBRELLA LIAB — OCCUR EACH OCCURRENCE S - EXCESS LIAB CLAIMS-MADE AGGREGATE .t – DEO I RETENTIONS ppTT S C WORKERS COMPENSATION ISTApER TUTE I I?V- ANE)EMPLOYERS'LIABILITY AApNN�YP(�RO�Mg6OERRpIPARRTTNN EXEWTIVE YIN UCEO? NIA WCC50050007062017A 12(0x2017 12/03/2018 EL EACH ACCIDENT S . IOQ000 RrAacdetorymNRO EL.DISEASE-EA EMPLOYEE S 100,000 11 es,describe under 500,000 DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT f DESCRIPTION OF OPERATORS I LOCATION91 VEHICLES(ACORD 101 Additional Remarks Schedule,my be attached If more space Is nquk.d) Certificate holder is an additional insured under General liability for ongoing operations when required by written contract or agreement. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE n of THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Tow Tow Route Yarmouth28 ACCORDANCE WITH THE POLICY PROVISIONS. 1146South Yarmouth,MA 02664 ' ' iAUTHORIZEDREPRESENTA7VE[//JCA,. ITY 7[i`r'e'" _ ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo ere registered marks of ACORD