HomeMy WebLinkAboutTR-19-1629 or TOWN OF YARMOUTH•
(4:3NY448(.p7' l G-.b Ul6 2�j,�g cBUILDING DEPARTMENT • Permit Number
• Or y 1146 Rotate 28. South Yarmouth. MA 02664
, ,•... Y, <p8-378-2231 ext.126I Fax 508-398-0836 Date Issued
•
Expiration Date
$50.00 •
TRENCH PERMIT
Pursuant to G.L.c. 82A $1 and 520 CMR 7.00 et seq.(as amended)
MIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Num of Applicant
`bei141 eP Phone Cell
Street Address p1, iJa & •
pj • • 8 a98'd+I� J�
� CP+—lQ►(�
C.
/fawn d� MA ZIP .
PU. I • . 0a631
Nate ofrotor(if differfrom applicant)
p , '. f� Phone •Cell
Street Add ` e kri L72di LLl 10 (.(, 5v�3. 9U9 - 9x7
Cit pwn •MA• ZIP , .
rtr ' 0A1;3 I
Name ofneds)of property r
- Phone •CeBertIdsvt ahi i •
. Street Aes
li 2e 24-1 KJ
Ch own S ZIP
•
61a `iarmuh
Other Contact
Deseriptton,location and purpose of proposed trench:
ri
Please describe the exact location of the proposed trench and its purpose(Include a description of what Is for is intended)to
be laid in proposed trench Legs pipe+/eabie lines etc..)Please un resent side If additional space Is needed.
. . .. cz3reit
` RECEIVED
SEs' 182018
IIts n n 1 eui a ,�e1i}i P =
Insurance _ r
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Pi
Name and Contact Information of Insurer:
£o eis anted 'L, < )nMf tair>,t e— 5)5. .39$..
Policy Expiration Date. ser- 10 !1f))' 791 •
Dig SJR M: A0 y-
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Nene of nmpet Person� y 53A CMR 7.02): •
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Ma setts Hoisting Lieense# cT�O - -gam r
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Utmost Gri t {{L"afl- • Expiration tit•
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BY SIGNING nag FORM,TEC APPLICAI1V7,OWNER,AND EXCAVATOR ALt.ACKNOWLEDGE AND CERTIFY ,
TEAT THEY ARE FAMILIAR WITH;OR;BEFORE COMMENCEMENT OF THE WORE,WILL BECOME FAMILIAR
WTI7t ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,
GE.- c. 82A, 520 CMR 7.00 et soil, AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND
REGULATIONS AND THEY COVENANT ANI)AGREE THAT'-ALL WORK DONE UNDERTHE'PERMIT ISSUED FUR
SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH
BELOW_
TILE 'UNDERSIGNED OWNER AUTHORIZES THE AYPLLCA.NT TO 'APTLY FOR THE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO, FOR THE
DURATION OF CONSTRUCTION'A.UIBORIZES 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 COVERING SUCH WORE-
TEE UNDERSIGNED APPLICANT,OWNER ANT)EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REIMBURSE TTM MUNIaPAIITY FORANYAND ALL COSTS AND EBPENSESINCURRED BY THE
MVPIICTAALTIY IN CONNECTION WITH THIS PERMIITAND TBE WORE CONDUCTED THEREUNDER,
DMCEUDINGBUT NOT LIMIITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF
. THISPERMI"T,INSPECTIONSMADETOASSURECOMPLIANCEItir.,tawita:ANDMEASURESTAKENBYTHE
MUNICIPALITY TO PROTECT THEFT/BM WHEETHEAPPLICANTOWNEROREECAVATORHASFAILEDTO
COMPLYITIEEtEWR'B INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED
NECESSARY BY THE MUNICIPALITY_ i •
• 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 MENSES RESULTING FROM OR ARISING OUT
OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK •
CONDUCTED UNDER THIS PERMIT.
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APPLICANT SIGNATURE
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" DATE f Jfr/!( } - .
CAVATIORSIGNATURE(IFDIPPIRENT) •• / (((
A . . A is,- �__ DATE �1��lvl�
,
OWNER'S SIGNATURE(IF DLFFEBEN,T)
• }
L .P�IGi La 2401:71,..."DATE_ 9/7//f
• For Ci3y/Towm-Da not writebbtit sa titer
PGRATITAfl2OVEDBY - _App6mtineF'ee•
PERMUTING ATTIROBITE" • Ilhae' - _ •
CO WUIONS eB.AEUROV:st . _ -. •.
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