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HomeMy WebLinkAboutBLDTR-19-2463 %'� gYq TOWN OF YARMOUTH o - ,, . % BUILDING DEPARTMENT Permit Number&DIR- 9-aDDif,3 p( fq c 11 ute 28,South Yarmouth,MA 02664 E' y v c_50- 98-2231 ext. 1261 Fax 508-398-0836 Date Issued -r+ am" ` Expiration Date atI 25216 M= • Maaadwatoe Hotdtng Ikea.M a X32 3 3 �—01 • I. Limn. Geode 2_A _Eapiratioo Date: BY SIGNING THIS FORM,THE APPLICANT,OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT THEY ARE FAMILLUH WITH,OR,BEFORE COMMENCEMENT OF THE WORK,WILL BECOME FAMILIAR WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORE PROPOSED,INCLUDING OSHA REGULATIONS, \' GL e. IRA, 524 CMR 7.04 d 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 TILE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE CONDMONS ATTACHED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH WORK. THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO REIMBURSE TILE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE MUNICIPALITY EN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER, INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATIC 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 TUIREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED NECESSARY BY THE MUNICIPALITY. THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND, INDEMNITY,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 THIN WORK CONDUCTED UNDER THIS PERMIT. 'CANT SIG 1p / DATE /D'2�/& CAVA OR SIGNATURE(IF DIFFERENT) DATE OWNER'S SIGNATURE(IF DIFFERENT) Michia- CkurerEm - 3/4,644Monteller6r Carp: to/z/zottt DITE: meCiliarts .-D.moi.rY.vastill ranlifI Tm� bAV®BY 3__Aponat.,re. Deer CONDftbHm c!' A _ 2 of 2 • .,i—""li LAMOBRO-01 LLAVIGNE • jaCbRO' CERTIFICATE OF LIABILITY INSURANCE DATE 0 /27/201 4...---- CERTIFICATE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER NAMEECT Oxford o37urance Agency,Inc.0 (HONE ). I FAx ):( AIC,No,Ext (508)987-0333 ikic,FAX No 508)987-5517 Oxford,MA 01540 teDAihss;infotoxfordinsurance.com INSURER(S)AFFORDING COVERAGE NAIC N INSURER A;Admirai Insurance Company INSURED INSURER 8:Commerce Insurance Co. • LaMountain Bros.Inc. INSURER C:Granite State Insurance Co. 37 Federal Hill Road INSURERD: Oxford,MA 01540 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUER POLICY EFF POLICY EXP I TR TYPE OF INSURANCED V,(VD POLICY NUMBER (MMIDD/YYYYI IMMIDDIYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY • EACH OCCURRENCE 3,000,000 CLAIMS-MADE X OCCUR REN OF FEIECC1083805 11/01/2018 11/01/2019 DAMAGE TD RENTED 300,000 PREMISES(Fa occurrence) $ X POLLUTION LIAB MED EXP(Any one person) S 5'000 PERSONAL&ADV INJURY S 3,000,000 GEN'L AGGREGATE JELIMITqo�APPLIES PER: GENERAL AGGREGATE S 3,000,000 POLICY X L'T fl LOC PRODUCTS•COMPIOPAGG S 3,000,000 OTHER: POLLUTION LIAB $ 3,000,000 B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 IEa acddentl S ANY AUTO BDTJWL 11/01/2018 11/01/2019 BODILY INJURY(Per person) $O — _ AUTOS ONLY X SCHEDULED BODILY INJURYpg (Per accident) $ X AUTOS ONLY X AUTI ONLY IParr aEttdent) MAGE S S A X UMBRELLA UAB X OCCUR EACH OCCURRENCE _ S 5,000,000 EXCESS LIAB CLAIMS-MADE REN OF FEIEXS1083905 11/01/2018 11/01/2019 AGGREGATE $ DED X RETENTIONS 10,000 AGGREGATE $ 5,000,000 C WORKERS COMPENSATION X PER 0TH- ANDEMPLOYERS'LABILITY YINSTATUTE ER ANY PROPRIETOR/PARTNER,EXECUTIVE EI WCO24-18-1092 09/30/2018 09/30/2019 E.L.EACH ACCIDENT S 1,000,000 OFFICER/M iMEE'EXCLUDED? ' I NIA 1,000,000 antlatory n NN E.L.DISEASE•EA EMPLOYEE $ If yes,describe under E.L.DISEASE•POLICY LIMIT E DESCRIPTION OF OPERATIONS below 1,000,000 A Pollution Liability REN OF FEIECC1083805 11/01/2018 11/01/2019 Per Claim and Aggreg 3,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 1 Of,Additional Remarks ScheduN,may be attached If mon spats Is required) NAIC#s for Insurance Carriers are as follows: 24856-Admiral Insurance Company 34754.Commerce Insurance Company 238990•Granite State Insurance Company CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 , AUTHORIZED REPRESENTATIVETI, I ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD