HomeMy WebLinkAboutBLDTR-19-001823 1
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TOWN OF YARMOUTH F.�IJTR-FR -OCIea3
0. , 4 BUILDING DEPARTMENT ' Permit Number
'A744 c ' 1146 Route 28,South Yarmouth,NIA 02664
O .n ..- si
' t .r,- 508-398-2231 ext. Fax 508-398-0836 Date Issued
Expiration Date
$50.00
TRENCH PERMIT
Pursuant to G.L. c.82A §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant /Re s x cc(vat o Phone Cell
/Li ICO.L Ea/ Q_ .5U$-�F77-t &63
Street Address
Email Address:
Say/Town MA ZIP
-fO(Fs Jale DZe 11
Name of Excavator(if different from applicant) Phone ' ' Cell
Street Address
Email Address:
Cityffown MA ZIP
Name of Ownerls)of Property AQ 1'_ t h_ OX 1(OZ Phone Cell
Street Address l,.// ?h /�C�C� 10y- 9 9 y-710 6
I ^ '121 eo Email Address:
City own MA ZIP
tomo uii-1)prl-
her Contact I Permit Fee Received No( 1 Yes( 1
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(eg;pipes/cable lines etc..)Please use reverse side if additional space is needed.
£-itC RECEIVED
SEP2s201B
BUI
iInsurance certificate I: sppoc LzoS,i s J
i Name and Contact Information of insurer.
I arle 51/11(e- $0 (at A4 ' acct SDB-gge-Srar
Policy Expiration Date:' ]
14 4 1
ID'Safe0: pen' k JX ti09 I
V a ompetten,PPerson l as defined by 520 C'%IR 7.021:
I
J'
• 1.
Name of Competent Person(as defined by 520 CMR 7.02):
T -�- Gt or
Massachusetts Hoisting License# 0.92170
License Grade: C)2 Expiration Date:4 7/a d
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,
G.L. c. 82A, 520 CbIR 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 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 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 O111ER REMEDIAL MEASURES DEEMED
NECESSARY BY THE MUNICIPALITY.
THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOLN'TLY 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
� 2A)C94( E �^ DATE Q4)la (tie
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
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