HomeMy WebLinkAboutBLDTR-19-002242 1/ w
TOWN OF YARMOUTH ATR-I�-Gct. y a
e-� YRkS BUILDING DEPARTMENT Permit Number
o '-al ° y 1146 Route 28,South Yarmouth,MA 02664
i„ $ , 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
c.
•
Expiration Date
$50.00
TRENCH PERMIT
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant CAP CAV tbo EPICA14tist(ago Phone Cell
&-477 -?2 n sob-367-(20).
Street Address Istu� CRDbLxbsewT&t(?YISE$
15'3 cog of t_51— Email Address:
City/Town MA ZIP
MA5NV6
Mot- 0 -fe
Name of Excavator(if different from applicant) Phone Cell
Street Address
Email Address:
Cityffown MA ZIP
Name of Owners)of Property. Phone Cell
C,41P0L ce4 (4,
Street Address
c3 n_ CWW4R 27Dc (L [lt) Email Address:
City/Town MA ZIP
Wesr Y4-tuccocrol Mr4 6a4..'73
Other 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.
RECEIVE
s�yN -4-1-t b OCT 16 2018
MEpFf
BUILDING DEIARi
By
i Insurance Certificate t: C3O7
i/;24:71.5
I Name and Contact Information of Insurer.
1406 ZNTD4 T7°MAC P.E. ( Tt(euPG. C4&i.e..eirtg-
Polley Expiration Date: 1q7--'11- ?b I R
IDig Safe N: A01A1 lI '{5ol
Name of Competent Person(as defined by 520 CMR 7.U2):
"1(11t GS DoE4oCr
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Name of Competent Person(as defined by 520 CMR 7.02):
,MES L D V F,40 Cr
Massachusetts Hoisting License# R L —� (Si age)
License Grade: C a A Expiration Date: &' 12 - ao i 1
BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF rim WORK,WILL 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 T LAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR
SUCH WORK WILL COMPLY THEREWITH IN A' RESPECTS AND WITH THE CONDITIONS SET FORTH
BELOW.
THE UNDERSIGNED OWNER AUTHORIZES T APPLICANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WORK 0. THE PROPERTY OF nth, OWNER, AND ALSO, FOR 1HE
DURATION OF CONSTRUCTION, AUTHORIZES ARSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE
CONDITIONS ATTACHED HERETO AND nit 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 0 MLR REMEDIAL MEASURES DEEMED
NECESSARY BY THE MUNICIPALITY.
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 EXPENSES RESULTING FROM OR ARISING OUT
OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING rat WORK
CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNATURE
11°— Cr. DATE ibl5 - ,,0 (g
EXCAVATOR SIGNATUREG (IF/DIFFERENT)
�-Ce DATE 1U - IS -420L3
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
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