HomeMy WebLinkAboutTR-19-1349 l '--s
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}oF,,gRTOWN OF YARMOUTH gL()TRA Cl -OCY3(tg
' deo BUILDING DEPARTMENT Permit Number _________
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pf -r 4 y 1146 Route 28,South Yarmouth,MA 02664
?'\, 3,v 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
Expiration Date
$50.00
\,_ TRENCH PERMIT
Pursuant to C.L.c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST SE FULLY COMPLETED PRIOR TO CONSIDERATION
Navas ofAppikant Rl,Obec"r O O ava_ co Phone
11'3?-0630
Cell
Street Address S6— 1(�'3?_05 0
(9.it G reA- i- (PpeS*C rid Rd
City/Town MA ZIP
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NameofExcavatorlifdWterentfromapplicant) / Phone Cell
Street Address Pk)L- CorliS
-Trig-a 01 rcAQ 7?Li--in6-7 91) 9
City/Town MA ZIP
Sh .69ce�wl� I 0a8 G a
Name of Owner et of Property Phone Cea
Street Addressigc= 'Y A • SI -4NdrQA 6, VC�l4P-Q
2 eroU2 Sr-•
City/Town I MAIZIP
�ty4)QMo�-rtii 9 0362)3
Other Contact I Permit Fee Received No( ) Yea( )
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/cable lines ete.)Please use resent vdde If additional space la needed.
? G rove. ST 1 CA -)" Sias 0E tuv5-e, S p , '
elAJStcv1l-ACion R CEIVED
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j SEP 05 2018
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i Insurance Certificate St C p n 130 / L)a_gar
i Nome and Contact Information of InsurerInsurer
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Policy Eepintlnn Datr. c ,aj) vi ) ¶ ��(I. n1
Dig Safe a 6 1 .— )6(7_ li��� V —
Name of Competent Penal as defined by 5 1.51R 7 On
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hhLicensemeetta Hoisting Lice. I N - J dab
Ocean Grades _• 515j/� TT
ExpirationDaft: �`V Da
BY SIGNING THIS FORM.THE APPLICANT.OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WI H,OR,BEFORE COMMENCEMENT OF THE WORK,WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED.INCLUDING OSHA REGULATIONS.
G.L. c. 82A. 5211 CMR 7.011 d aeq., 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 'Mt 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 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 SI
DATE *ling
EXCAVATOR, SIGNATURE(IF DIFFERENT) 1; DATE S\ti 1`'IC1
OWNE"S SIGNATURE DIFFERENT)
AT) , •-e .j. % DATE: 4UOi� C
Far titans -pow art Is di
ITRAPSMI'IAff1UV®BY Applicationlu
CONDITIONS *A A4� Oast
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