HomeMy WebLinkAboutBLDTR-19-001516 TOWN OF YARMOUTH
o ;tilt 1-D-72 - /�-�lS/1.
- :z 4.:, , gyp, � BUILDINGDEPARTMENT . : Permit Nu7.m er
,o '`', ,°yt C 1146 Route 28,South Yarmouth,MA 02664
N ' 1 - d4 ; 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 BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant Bk., 53 £xcatlo.4io" Phones°a 1177 0653CeIl
Street Address f4 TeaSerrt./ LrJ
Email Address:
City/Town MA ZIP
Fr'cs4aL\c.,, ,;. tom' , Oo761414
Name of Excavator Of different from applicant) Phone Cell
Street Address '
Email Address:
City/Town .. MA ZIP
Name of Ownefls)of Property VCro. SabrCi ret.. Phare Cell
Street Address 9 'feta i Biro( LPO '
Email Address: '
City/rown MA ZIP
Qar& ovi k ✓'
Other Contact , I Permit Fee Received No( 1 Yes( )
Description,location and purpose of proposed trench:
Please describe the tact loader'of the proposed trench and its purpose(Include a description of Mint is(oris intended)to
be laid in proposedtrench(es,pipes/cable tines etc_)Please use reverse ddeif additional space is needed.
Trcne>\ -iron\ tcxn H -{o )Veto I<acin n l et.re- Inca")eo4
on -{he Ice side, eV c/lt,,3e,i11,49 RECEIVED
•
SEP 13 2018
l BUILDING DEPARTMENT
E .
I
Insurance Certificate 0: 543900000o //SZT
•
I Name and Contact Information of Insurer.
Policy Expiration Date:
IDig Safe it: 2014S3110130 ,
Name of Competent Person las defined by 520 CMR 7.02):
, Rtc1ctt Or vihi •
i \4
•
Name of Competent Person(as defined by 520 CMR 7.02):
ic.K4;,t )rkh
Massachusetts Hoisting License# H C O y$1 TIO
License Grade: _NE z A Expiration Date: 2-)1 2°
BY SIGNING THIS FORM,THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAME :LARIVITH,OR,BEFORE COMMENCEMENT OF THE WORK,WIT T,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.
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 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
MUNICIPALTTZIN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCT U;D 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'LIABHTY,'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
Qt4PrOte, gtt_CLO� DATE 9- 13 - ,S
EXCAVATOR SIGNATURE(17 DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
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