HomeMy WebLinkAboutTR-19-1377 t -,w
•
0f '4411.
' TOWN OF YARMOUTH (,p7'(2,.,Iq-bb1377
;• 4o BUILDING DEPARTMENT Permit umber
g ,�g y 1146 Route 28,South Yarmouth, NIA 02664
'c',, .e,,,, ,y_Z' 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
Expiration Date ,
$50.00
TRENCH PERMIT
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST RE FULLY COMPLETED PRIOR TO CONSIDERATION
Naar of Applinnt R OTI_-k3 oV 62.. CO . ePhono ? Cell
StreNAtltlrL%14 /-.C.�T kaaTerni r2�/ 5'0 ....LI
J�_�5
CI /town l� MA ZIP '
Nano of Exca ata Of different Irma applicant) Phone Cell
Street Addr��"t_ Curti
rri�.N l-a, CI,rCsle
���� '— 2Q�q
City/Town MAIZIP
(CA>�PI'R..)1Cln- Mt OR c-b3
Name of Owner(*)of Property Phone Cell
W GAebr Rate -fr'i&r
Street Address
'151 rvtquj ST Og1- 15_ 0
City/TownMAZIP
kit' (0-01011) IAA/ I o t' c
Other Contact f Permit Fee Received No( 1 Yes( )
Description,locatdoa and purpose of proposed trench:
Please describe the met location of the proposed trench and its purpose(Include a description of what is(or is intended)to
be lad In proposed trench leg;pipes/able lines etc.)Mate use revere ride If additional upas Is needed..
6a. Grew)" tlpescec i•/ rad , t Etsrre_ LeS .'IjST¢Il New Aclu-ck,,try)
€) cc,'A -e. ccir- 1 wSt ¶ &ivelq nDM 2u�a Scr c, 31SSen
•
RECEIVED
Insurance Veridical*•tSEP - 6 2013
°A I 0 C1a a w .,rr. ..!
Name tad Contact information of Insurer. By Yi1: ��7�t
/14°$ ZNre r Q
aN L • te E,�
• Policy F_epinsMn DannP- a _-_
DIS Safe I:
Name of Competent Peruos las defined by 520 C% R 7.02):
Al we Od rioci9-e
1 oft
L ,..:
6haadiusetts Hoisting License I ^� ?
Lieenre Cracks �GoLC�J Expiration Dates S ��i ao
BY SIGNING THIS FORM,THS 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,
C.L. a IRA, $21 CMR IN et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND
RECITATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER TILE 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 ID
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 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/7;524E G J
DATE OG ) l rg
EXCAVATOR
�SIGNATURE(IF DIFFERENT)
Phi R DATE AA6371
OWNER'S IGNATURE(('AFFERENT)alr
��
? DATE: 5L Li I
l/
Foe(T�/Ttnswas-atat eft Is*1
KAAI}f irrarPon � i��FP4ads.1 e
PRRSiTF INGI Aara
commits.01► ATS
2 of 2