HomeMy WebLinkAboutBLDTR-19-001630 7F ..........01.y44 TOWN OF 1'ARAIOUTH �c,t�T2- let -(� (�3 0
�3e. . ,.� do BUILDING DEPARTMENT Permit Number '
• n, ,. 1146 Route 28. South Vanua nth. MA 02664
.,t•;,, i i'Z' 5O8-398-2231 ext.I261 Fax 508-398-0836 Date Issued
• • Expiration Date
•
$50.00 '
' TRENCH PERMIT
• Pursuant to G.L. oa 82A $1 and 520 CMR 7.00 et seq.(as amended)
/THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name ofApplkantalu(� ,,.. _I llerc a:4 t—� Phone
t.� a 61 c l.t Cell
streetAddresa& Nau (.rm 2�! • • 3.398.P-1)1p soS•3aa--lo)o
C frown I HA I ZIP •
Name oftutor Of diffe from applicant) Phone
i,LIAL L"�e.au.lto..(.t, ceu^�Street Adov • 9�9 -gal
‘51 -' i .16/ . .
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A• ZIP ; /. �:r�,,, .
Name of Ow I DAL'S(
krys)of Pro�ety
(tuia cat nm. I',ono& ph"'! Cell .
Street Address
(0 o 00-6(�unds);Y sae -3q'�_ sg sb
Chown I MA I ZIP •
Other Contact i Permit Fee Received No( I Ya( )
Description,iocatloo 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 Wd in proposed trench(est pipa/cabte lines etc..)Please use reverse etde.if additional space is needed.
r RECEIVED
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`' U �y SEP 18 2018 •
. • BU 1 • P' F .-moi
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' insurance Certificate St
Name and Contact Information of Insurer
Pogers akd 67 0 Sillaflt e, $ .3q8-7,1 -1
! Polley Expiration Date:•
Dig Sete//: (9_0
01 y '
Name of n to 1�Person .6 O r 1 1 q
pe ft ned by S29 CMR 7.02):
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eg.?r3.2028 11:25 Linda Cranmer/Linda Smith 5083945856 PACE. 1/ 1
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M'saach°settsRavi*Lke®oe# //gag/71.53r ,
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License c -ars
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DT SIGNING t
TEAT NING RBF APPLIcCaA�T•,OWNER,AND EXCAVATOR Mat ACKNOWLEDGE AND Comm
WTTH;OR,'SE.FORE COMIv>ENCEMn4T OF THE WORE,WILL BECOME FAMiLiAR
WITR,ALL LAWS AND REGULATIONS APPLICABLE TO WORE;PROPOSED,INCLUDING OSHA.REGULATIION
GL. c. STA,
$20 AND TBEY COV . seq., AND ANY APPLICABLE MDHICprAL ORDINANCES, AND
• SUCHREGULATIONS
roa
WORK WZLL COMPLY AND AGREE TgA1'ALLWORE DONE UNDERtTH
• BELOW. T IN ALL RESPECT'S AND wan TSE CONDITIONS ISSUED
TRE UNDERSIGNED OWNER AUTHOXIMES Tl
EXCAVATOR TO Won ON T CANT TO 'APPLY FOR R. D ALSO AND
5'•,� . DURATION Ct CONSTRUCTION AUTTIORITES PERSONS PE ITRENII OWNER.1 AND ALSO, )POR TO
:5,,' ' > UPON TDB PROPERTY TO MO APPOINTED BY THS CONFORMITY
ITII BTO
E
:_' CONDITIONS ATTACIDP D HERETO App 'H T08 AND 1NSPEC3 TH1E WORE FOR CONFORMRTY WITH.TBE
7 •r TO _ ._ TITS LAWS AND REGULATIONS GOTS a STIOI WORK.
�,r,• TSE PIPERBIIGNEDAPPLICANT,OWNER AND RYCAVATORAGREE 30RNTLYANDSEVERALLY TO
REIMBURSSTE E MUNICiPAT=FOR ANYAND ALL COSTS AND EXPENSES INCURRED DY TIM
MUNTC PAUrnRNCONNECTION WITTE THIS
TREY BQ TEE WORE CONDUCTED 7yINCLUDING BUT NOT UNTIED TO ENFORCING 1H@RTS OF TATE I.AW ARD CON
OF3 •ITIONSADE OASSMECPIC,ANDMZAS /NETTHOMUNICI� � runicIAPPLICANT OR ATO RAS
FAILIaT
pT88RWTlINCLUDINGPOLICEDELA LSANDOR RMSDTJ ,MEASURES DEEomED,NECESSARY DYTEE MUNICIPALITY-
INDEMNIFY,coMPLY
• 'ITC UNDERSIGNED
AND BOLD 'OS'1nMUNTOPALTIT Rt DtALL JOOF us AGENTS SEVEItALLYNDIEMPL TO S FRO
ANY AND ALL L RABEL><TY,CAUSES OR ACTION,COSIB;AID EXPENSE AND OR AB869 FROM
OP ANY INJURY.-DEAIN,+LOSS,: OR' DAMAGE TO ANY j RESULTING FROM OR TRE WORK
CONDUCTED UNDER TRb9 PERMIT.,:•--t`p,.- .I' - PERSON OR PROPERTY DDluN6
TITRE WORE •
•
APPLICANT SIGNATURE ,.
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CAN-ATOR SIGNATURE(IF DIFFER
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-�t�.�'DAT10 11
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OWNER'§SIGNATURE(IF D
IFk1RENE) ,
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Received Time Sep. 14. 2018 12:29'PM No. 9016