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HomeMy WebLinkAboutBLDTR-19-001452 • fD TOWN OF YARMOUTHBIBUILDING DEPARTMENT Permit Number 1146 Route 28,South Yarmouth,MA 02664 ,,� 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 IPERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant obe`i 0-0pQ, C6?rzC Pham Cell Street Addrew 5(5`6.-4 3a -o s 36 ClryRown . `_ H A£ OlC1% 1 ... • Name of Exemplar(if different from applicant) Phone Cel Ph til-- Cul` 1c Street Address ,-AN , e rc.s - in L1- g 3 6-gen 1 City/Town ® ZIP Oa, 6 Nasset�OwnerlslofPro�r Phone Cell tie/WAS 8 r IS 80 Al Street Address a ,P GA QS\ i.e.)- So — , )fl Ch7/I own Kg ZIP D . 1 no-c Oda . (_ Other Contact ilrfirefini Description,toadies and purpose of proposed trench: Please describe the exact location of the proposed trench sad its purpose(include•description of what Is(or is intended)to be Idd in proposed trench lees pipes/cable linea etc..)Please use serene side If additional space Is needed. 10L ClMippw &meso circle. ReAr 4A3a0nnn• , 1�,v4S21 ` p i c. StSS� M ['/Seed!I QS")an) R E C E I / © SEP 1 t 201 BUIL - ��Fii • o ` O0 Insurance Certificate s: C' P A 1 30 1 4a. 8ac.__. Nems sod Contact information of Insurer: /� HU Q ZarerNetitoLm_ et.e] £3 ,AC Pol FA drstlon Data FWIYIt _-.- Die Safe 1: • sge" 370 ` CP et Name of Competent Person las defined by 520 I.Mit 7A21: tof2 .114 Maastichwstte Hoisting Licence 11_` ' l ca 6 33• + License Greeks _Expiration Date SI 91 0 0 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, C1— e. 82A, 526 CMR 7.06 d seq., AND ANY APPUCABLE 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 MIL 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 LAMED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF THIS PERMTT,INSPECTIONS MADE TO ASSURE COMPLIANCE TREREWmI,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 SIGNATURE DATE Q1ll boll EXCAVATOR` SIGNATURE(IF DIFFERENT) E� `1x ettitd, DATE C*\‘0\A OWNER'S SIGNATURE IIF DIFFERENT) LSA t[Inn-s„ DATE: Ct(Pi/ 1 For CH*T/T,n —Da boat eft Y dam cotaxtiotil 0=44 :. 2of2