HomeMy WebLinkAboutTR-19-001347 V4 :
V.
`f - Y TOWN OF YARMOUTH . (3LuT�lq --Du 397
Of '4k
.� S ._' BUILDINGDEPARTMENT ' Permit Number
o , trtV,i C 1146 Route 28,South Yarmouth,MA 02664 :
N ' I;' a , .- 508-398-2231 ext.1261 Fax 508-398-0836 Date Issued
Expiration Date
$50.00
TRENCH PERMIT
Pursuant to G.L. c.82A §1 and 520 CMR 7.00 et seq.(as amended)
THLS"PERMTr MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant 3 43 F-t(cavn4ion Phone
So$ in", OG53CeU
Street Ammo PI Tca.Scrry w .foresicLic
Email Address:
City/Town MA ZIP ..'
Dac4q
Nance of Excavator(if different from applicant) . Phone Cell
Street Address
Email Address:
City!1•own MA ZIP
Name of Owneris)of PropertyPhone CMI
Kail.lccn Kcnny
Street Address 434 N;91,60.4-,R Rot
Email Address:
City/Town MA ZIP
(i?o,rrnOtilk
Other Contact ----- 1 Permit Fee Received No( 1 Yes( 1
Description,location and purpose of proposed trench:
Please describe the Matt location of the proposed trench and its purpose(include a description of what is(or is intended)to
be laid in proposed trench(egg pipes/cable lines etc_)Please use reverse side It additional space Is needed.
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BY
i InsunnceCertifkateS: 5PP000000
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1 Name and Contact Information of insurer.
.DA OA Byrnc rids Aquncii - Nur/c Sy; Ile—
Policy Expiration Date:
I
Dig Safe N: zolg30os89S7
IName of Competent Person las defined by 520 CMR 7.02):
RoSt ri G;Kbc{
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Name of Competent Person(as defined by 520 C1IR 7.02):
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Massachusetts Hoisting License# HE- O 48►7O
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License Grade: P E Z/4 Expiration Date: 2 ' 11 ' Z O
BY SIGNING TELLS FORM, THE APPLICANT, OWNER, AND E$CAVATOR 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. c. 82A, 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.
rw 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 GOVERING 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 ILL'.L.IABH TTY, 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
CONDUC:rE7)UNDER THIS PERMIT.
APPLICANT SIGNATURE
er
' 9 e DATE 8-al - Y2
EXCAVATOR SIGNATURE.(IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
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