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Home My WebLink AboutBLDTR-19-001351 01.1'44. ;YqR TOWN OF YARMOUTH in 1-491 -1Q-D b(3s t .7 .5.4%. o BUILDING DEPARTMENT Permit Number , t ID ,-, y 1146 Route 28,South Yarmouth, MA 02664 ;!C:. � .�,� 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued Expiration Date $50.00 TRENCH PERMIT Pursuant to G.L.c. 82A 41 and 520 CMR 7.00 et seq.(aramended) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Naw of Applicant G.G . eoM brei ctl, feel C. Phone CeD Street A ,e (So$1.31.94311 ddre /S DIA-�tto4[ls Pitrif City/Town I MAZIP s�/r proJdns, Nv} , 026,6o Nap of Excavator lit different from appilcant► Phone Cell Street Address .54114E AS 4-do✓E City/Town I MA I ZIP Name of Ownertsl of Property p Cetl AddressKA-L L A'tJDEK6oJ Street to R.r✓EIt olive c Cky/townMA ZIP Soffit y� yr/ I Other Contact --1 Permit Fee Received No( t En l ) Dnerlption.loadoa and purpose of proposed trends Please describe the met location of the proposed trench and its purpose(Include a deseripdon of what is(or is intended)to be laid In proposed trench leg;pipes/cable lines etc..)Please use revene side If additional ware is needed. To to sUfa uPGR4.00 Wilt. Sys7CL 73 i.da.VOC new /40 ate.[.n.J cern. rt-mc NO tlnt(9) Soo 4fu.wl tacit Ammons, wott to YE dome 47 gte.ic. ,&o crag ikhdp sip( se puitiv, RECEIVE 1 SEP 05 2018 i i Imunnal'ertiflcfl L BUIL i — trr#cp&D "` Li s �tS By Name and Contact In/ormatlon of Insurer. HUB DITE-tamresAt cc NE$0J46nvD 21-2 HI U.114£4 8a 'Ito Tkw heel-,AA. cAYe6Rt+eet„,icwe (sot) 2.3S. 210} • Polky Eepinuien Date. S4cy tot Dig Safe F. 2018—340— /7Y, Naw of Competent Pence l as defined by$20(SIR 7.02f: 1 of 2 4. Massadmsetta Hoisting Lionel ThD NE- l I4 5/ License Gnde: ZA. Expiation Date: P G/2o18 BY SIGNING THIS FORM. THE APPLICANT, OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT THEY ARE FAMILIAR wait.OR,BEFORE COMMENCEMENT OF THE WORE,WILL BECOME FAMILIAR WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS. G.L. e. *2A, S2111 CMR The 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 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 MUNICIPAUTY IN CONNECITON WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER. INCLUDING RUT 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 'ITIS WORK CONDUCTED UNDER THIS PERMIT. Al — APMISP , `iar1117iin ' aB DATE EX "`"ATOR SIGNATURE IIS'DIFFERENT) DATE OWNER'S SIGNATURE II+DIFFERENT) DATE: Far CRilTrne a—Di S vttU S dilisdat PRTt1I WARY tL postle.►a . IERbIVdA C �T1TDfa OUIIR DiA Dor 2 oft �...4, CCCONST-02 CLAWRENCE ACORO' CERTIFICATE OF LIABILITY INSURANCE DATE(CIM DDM VL) /,. 06/28/2016 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 REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)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 endorsement(s). PRODUCER License#1780862 NanNiEncT Catherine Lawrence HUB International New England imc,"No,EXt):(508)235-2207 FAXA/C,No): 222 Milliken Boulevard Ek/A1 Fall River,MA 02721 s ppR ss:Catherine.lawrence@hubintemationaLcom INSURER(S�AFFORDINO COVERAGE NAICI INSURER A:Firemen's Insurance Company of Washington,D.C. 21784 INSURED INSURER 8:St.Paul Fire&Marine Insurance Company 24767 C.C.Construction,Inc. INSURER C:Acadia Insurance Company 31325 15 Diamond's Path P.O.Box 1493 INSURERD:Markel Insurance Company 38970 South Dennis,MA 02660 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 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. INSR ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/Y1'YY) (MM/DD!YYYY1 LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ _ 1,000,000 CLAIMS-MADE X OCCUR X CPA509678515 07/01/2018 07/01/2019 EREMISETSpawcr encs) $ 250,000 _ MED EXP(My onepemon) $ 5,000 PERSONAL BAW INJURY $ 1,000,000 _GENI AGGREGATE LIMITo-APPLIES PER: GENERAL AGGREGATE $ 1 2,000,000 POLICY X SECT fl 1 LOC PRODUCTS=COMP/OP AGO $ 2,000,000 OTHER: EBL AGG $ 2,000,000 A AUTOMOBILE LIABILITY COMBINED udan SINGLE LIMIT £ 1,000,000 X ANY AUTO MAA5096788-15 07/01/2018 07/01/2019 BODILY INJURY(Per pe,son) $ OWNED SCHEDULED AUTOS ONLY _ AUTOS SSWryEp BODILY INJURY(Per eccldeniL£ AUTOS ONLY _ AUTOS ONLY PROPERTY emdent)AMAGE £ $ B X UMBRELLALIAB X OCCUR EACH OCCURRENCE S 10,000,000 EXCESSLIAB CLAMS-MADE ZUPI5P7771518NF 07/01/2018 07101/2019 AGGREGATE 10,000,000 3 DEO X RETENTIONS 10,000 $ A WORKERS COMPENSATION X STATUTE PER ER ATH- ND EMPLOYERS'LIABILITY1,000,000 ANY PROPRIETOR/PARTNERI/EXECUTIVE Y/N WPA509679215 07101/2018 07101/2019 E.L EACH ACCIDENT £ (Mandatory In NH) N EXCLUDED? N/A 1,000,000 E.L.DISEASE-EA EMPLOYEF� If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C Equipment Floater CIM5101396.15 07/01/2018 07/01/2019 leased/rented 325,000 D Pollution/Environm MKLVIENV100337 07/01/2018 07/01/2019 Each occlagg 5,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more specs Is required) Re:2017 Septic Permit CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth ACCORDANCE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ACORD 25(2016103) O 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD