HomeMy WebLinkAboutBLDTR-19-002338 / I _J
., r ► TOWN OF YARMOUTH 3T2-Iq1-6( 33
°f.YAR BUILDING DEPARTMENT ' Permit N umber
p ;t;.4 C 1146 Route 28,South Yarmouth,MA 02664
•N „ ri;,c4' 508-398-2231 ext.1261 Fax 508-398-0836 Date Issued
,''_�,4... .3'td "
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 ( }0&WtvE ek1re(YRIScc PZ13,0 $oe De-tt7t-$$"f"j Cell Spy 7-1$0a.
Street Address 1110EE e> GEP6WtD'c t✓Te[ yN
(
53 COMA4 (AL- .5772EEr Email Address:
City/Town MA ZIP
M/tSH('EC Mft oa4,449
Name of Excavator(it different from applicant) Phone Cell
Street Address
Email Address:
City/Town MA ZIP
Name of Ownerls)of PropertyJ &d MCAD Phone Cell
Street Address _
(CO CA-'p—r`BACON) RQ4r Email Address:
City/rown` ' MA ZIP •
t.,i
sat YA1L.4coun[ MA X.44
Other Contact I Permit Fee Received No( ) Yes( )
Description,location and purpose of proposed trench:
Please describe the exact location of the proposed trench sod its purpose(include a description of what is(oris intended)to
be laid in proposed trench(eg;pipes/cable lines etc..)Please use reverse side if additional space is needed.
@PVC T1& ' RECEIVED
•
OCT 19 2018.
�IIIUIera t3) '
I
Insurance Certificate Si: CPA
1301
t /YD.2 a S
Name and Contact Information of Insurer:
HUB l uTec7d.�ETICNr4, Ij..& CATtlESZIOG CA -e-ic
Policy Expiration Dale: (a,-1— 361 -
I Dig Sate if: ^ )( g 32o1 (IQ
Name of Competentoo''�` Person las defined by 5201 CMR 7.02):
TAWleS DUFRvr -j
e _c-
Name of Competent Person(as defined by 520 CMR 7.02):
,MES P . 1� VcAUc- r
Massachusetts Hoisting11License# H E-.. c'' a
License Grade: C'1 - a
Expiration Date: Csa` /9 - ao t
BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF THE WORK„WELL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,
G.L. c. 82A, 520 CMR 7.00 et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND
REGULATIONS AND THEY COVENANT AND AGREE 7.TAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR
SUCH WORK WILL COMPLY THEREWITH IN A' RESPECTS AND WITH THE CONDITIONS SET FORTH
BELOW.
•TILE UNDERSIGNED OWNER AUTHORIZES T APPLICANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR DURATION OFOCONSTRUCTION,ERTAKE UCH WORK O. ME AUTHORIZES _•ERSONSODULYYOF THE APPOINTTED BYBYTHEMM�aP FOR
PYO
ENTER UPON flit. PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH 1HL
CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS GOVERING 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 TIES 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 COiMPLIANCE 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 OTH .R REMEDIAL MEASURES DEEMED
NECESSARY BY THE MUNICIPALITY.
THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDEMNIFY,
HARMLESS E MUNICIPALITY AND ALL EMPLOYEES AND ALLLIABILITY, EXPENSES RESULTING FF rrs AGENTS ANDROM ARISING OUT
OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNATURE .
-ika-Car DATE f0 Qig
EXCAVATOR SIGNATURE(IF DIFFERENT)
CCc DATE t`t) tel - I�
OWNER'S SIGNATURE(IF DIFFERENT)
•
DATE:
'ere*.w �� rt P%""�µ+^a./ i8r¢lil ih �3 ' it ,es,�,y
.mss-' i;5� 8 ti+}zLI[ aj�(G1�eG�101 %' a'L S" s.=i "yta a src�ty
� i k .3? rgen'fid i�" ,dF' ir. fr - : £ }[ Px..,v rz � a aa:F
.�. .... .. _ _ § ° W �,Fe4gi c.s.� tvint3 l �`5'k's-*#-.f-�'-`�' r attirC zi '1"+-.r W s.�`Z.h�,