HomeMy WebLinkAboutTR-19-1939 iii
04''"'�R TOWN OF YARMOUTH I B -1g-001g-39
�'' o BUILDING DEPARTMENT Permit Number
s' '=,,IIP e I
o .t 4 1146 Route 28,South Yarmouth. MA 02664 i Date Issued
te% 1 ��4' 508-398-2231 ext. 261 Fax 508-398-0836
Expiration Date
$6°
TRENCH PERMIT
Pursuant to G.L.c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
TIfIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of ApplicaTM Nm-twAvoes anc,,phone Cell
Street Address 35X 115 We -e5' -SCJ;
City/Town MA ZIP
eI.ILS _ (52404-1
Name of Excavator(if different from applicant) Phone Cell
Street Address AA
tAAV
City/Town 1 MA ZIP
Name of Owner(s)of Property 4, cAt
`,.v
Phone Cell
St ddess ttcg. /Ac-1,
City/Town MA ZIP�yWaC91 �
In P
entdt 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(eg;pipes/able lines etc..)Please use reverse side if additional space is needed.
6/C4Ta ‘F0e-- 5 Pik- t k viD ix
RECEIVED
OCT 02 2019 l
r^ _J
Insurance Certificate#: �a . 4 BUILDING DEPARTMENT
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By.
Name and Contact Information of Insurer.
EAStEgN In t—RKI,S :
Policy Expiration Date: 04 L — `
Dig Safe 1: 7/Q�^'��J, r� S-jten{ (�]) `
Name of Competent Person(ams de sued by 520 CMA 7.02): J
cT,t1)r01c—Ce.— \L 'M c'finUV tcLLJ
1 of
-- — Ma�hnvett.___ _ cio _ i f
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License Credes Expiration Dat: 4-161-•
BY SIGNING TMS FORM,THE APPLICANT,
THAT THEY ARE FAMILIAR OE CO ,RAND EXCAVATMMENCEMENT OR ALL ORENOWL BEC CEROME TIFY
Wars.ALL LAWS AND REGULATIONS APPLICABLE WORK PROPOSED.INCLUDITHE WORK, NG WILL
REGULATIONS.
GL e. 82A. 528 CMR 7.00 d seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND
REGULATIONS AND THEY COVENANT AND AGREE THATALLWORK-DONE UNDER TIM 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 WORE 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 CON ORMTTY 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
MUNICIPAIJTY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO
COMPLY THEREWTImm INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED
NECESSARY BY THE MUNICIPALITY.
•
THE UNDERSIGNED APPLICANT.OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
AANNY LIABILITY.CAUSES OOLESS RAC TION.�COSIS,AND EXPENSIM RESULTINGALITY AND ALL OF ITS ARO E OR ARISING
FROM
OF ANY INJURY, DEATH, O OR DAMAGE TO ANY FROM OR OUT
CONDUCTED UNDER THIS PERMIT. PERSON OR PROPERTY DURING THE WORK
APYLICANT SIGNATURE
aux DATE
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EXCAVATOR SIGNATURE IIT DIFFERENT)
DATE
O H' I NATURE(IF DIFFERENT)
Et UATFa
MEM APPROVED RV
FarCRIT.r-DRtat•efeeleEdd
.7 A . .�Ap Beadan Tee
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