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HomeMy WebLinkAboutBLDTR-19-001715 iClitir TOWN OF YARMOUTH i ,(072.- /9 —oorps— fir eBUILDING DEPARTMENT • Permit Number • g y 1146 Rotate 28. South Yarmouth. MA 02664 'a'r 508-378-2231 ext.1261 Fax 508-398-0836 Date Issued • Expiration Date $50.00 • • TRENCH PERMIT Pursuant to G.L.c: 82A Hand 520 CMR 7.00 et seq.(as amended) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant/I i � and_I lel t e, Phone & geld Y►l Cell Street Address- Naultt.CV) pd �J S.9$ I lta J*0$ 3� �JO 10 C ,/I ow°. I NA I ZIP . Name of Excavator(if diffe from applicant) Phone CeU AjP� e�iil62t 5v 3 . 9g9 - gayStreet Add 151 — af,eti ' L CIlmwnMA• . • le'e Name of Owner rys f Pro D `J I �i Peery. Photic .Cell , --- 2/2S-Till • StrMAddr iViereee &iU j 9 gr f fM etod 110 005 -353 -197-Z City/Town I MA I ZIP • litowmittio 4-- Other Contact I Permit Fee Received No( ) Yes( ) 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(es;pipedeable lines etc..)Pleaseµse muse fide If additional space is needed. RECEIVED ! HEP21 • 2013 1 • • BUILDING DE PARTMEN I • BY Insurance Certificate M: — — Name and Contact Information��RYureo IC;10 • P-D3ers awd •tsi 0 lmuAaAvet, rOs• •398'19I 7 Polley Expiration Dar* ' Dip Safe IA " ) y-' �viS'= 381 2-938 Name of ompeteit Person I • tied by$20 CMR 7.02): i ••I IL . 1.of2 S. • Is .. M u .s/CotsangLicense g gE©f 3 — ' is License Grade ► G- a/q • ;radon Dista t BY SIGNING THIS SO � BY SI THEY AREFORM,FAMILIAR APPLICANT, OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY' WITH,AIL LAWS AND REGULATIONSOAPPLICABLE WORKPPRE COMMENCEMENT OF D,INCLUDING WILL REGULATIONS,IR C L- c. 32A, 620 CMR 7.00 et seed., AND ANY APPLICABLE MUNICIPAL ORDINANCES, REGULATIONS AND THEY COVENANT AND AGREE THAT-ALL WORE DONE UNDERTIDLIT LAWS AND S SUCH WORK WILL COMPLY THEREWITE IN ALL RESPECTS AND WITH THE CONDITIONSKIT RT BELOW.. THE U DER IIGGN OWNER AUTHORIZES THE APPLICANT TO 'APPLY FOR THE PERMIT AND THE XATOF CONSTRUQ SUCH WORK ON THE PROPERTY OF THE,OWNER, AND ALSO, FOR TEE DURATION UPON THE PROPERTY; moom ANes D PERSONS DULY AplO>NTRj BY THE MUNICIPALITY TO ENTER LONE ATTACHED INSPECL THE WORK FOR CONFORMITY wan Tim HERETO AND THE LAWS AND REGULATIONS COVERING SUCH WORE THE UNDERSIGNED APPLICANT,OOERAND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO latim UBSETIM MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSESINCURREO BY THE MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORE CONDUCTED THEREUNDER, INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF THIS PST,INSPECTIONS MADE TO ASSURE COMPLIANCE SAND MEASORFS TAKEN BY THE MUNICIPAIITY TO PROTECT THE runic WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO NECESSARY B LICE DETAHS AND OTHER REM�IAy MiTsASQR DEEMED r THE SIGNED FUNDER AND HOLDuHARMT OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND, IND ,ANY AND ALL LLABILITY,CAUSES OR ACTION,COSTS,AND EXPENSES MUNICIPALITY AND ALL OF ITS ANY ANTING FRO EMPLOYEES FROM OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON ORP OPERTY DUM OR ARISING OUT RING THE ORE • CONDUCTED UNDER THIS PERMIT- • APPLICANT SIGNATURE • ,r 11 ,i. - — ,e DATE "1 I •) • D► CAVATOR SI ,�� :zrar"moi SIGNATURE(]F D /`� �'� ` �l-,< ..)DA TE St.- O flt" SIGNATURE(IF DIFFERENT) 1 , _ '116.13P. ,P I g f uh DATE: (1 l 1 %\ • PERMIT APY'ldOVfiDBY YisCmtvlTownrae—Do not write%tMosection , PERMITTING mons . • Date •• t-!AFl�tioaPee. CONDTT'IOI.S O$APPEIOVAFg, , . c• - • , , • 2of2 ` , • k•