HomeMy WebLinkAboutTR-19-2595 A nr vAlt TOWN OF YARMOUTH 6c-iJTIZ-1�i- S9,S'
` t }= BUILDING DEPARTMENT Permit Number
0
p( r' C y 1146 Route 28,South Yarmouth, MA 02664
\\.__.;I„ .2' 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
Expiration Date
$50.00
TRENCH PERMIT
Pursuant to G.L.c. 82A 41 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE MST COMPLETED PRIOR TO CONSIDERATION
Nan dA Applicant
PPl Terry Walker Excavation lnc Phoma CeR
Street Address 508-509-5870 Box 115
508-509-5870
West Harwich,MA 02671
City/Town I MA 1 ZIP
Nowa of Excavator(if damns from applicant) phone CAD
Street Address Same
CItylrowm. IMA
1 ZIP
Ns"d Ownen"d Property George Davis Its Cm
StreetAddress St.Davids Episcopal Church
205 Old Main Street •
City/rowsMA ZIP
South Yarmouth J 02664
Other Contract I Pero*Pee Remised Ns( ) Ya( )
Dusedpdo ,leaden and parse of propsxed trader
Please drseeibe the cart loads,d the proposed trench rod its purpose Itmchude m
description at that Is
be lald In proposed trench test pipeefcabk Baas etr_l nesse we none skit If additional spin Is needed,for L Intended)as
As per plan RECEIVED
OCT 30 2018
eui .1 . ..-rr �
BY:
Iniunnee Certificate St
Liab#MPP5811 L exp.02/07/19 WC#WCC5005011714 exp.02/07/19 Auto#M1T1737L exp.08/24/19
Nun and Contact Infenaatkme d Imam
McShea Insurance Agency 508.420-9011
: Pi.&y P-apintlon Mir
iOle
Soh~ 2018-4403508
Yams of Competent Prnmu to dkfned by 520 CM*7.12b
Terry S.Walker
1 012
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1 •
Mu_dmretee HahtME LJeeew 1 HE 041513
•
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Wenn Grades 2A
Expiration Date: 05/15/19
BY SIGNING THIS FORM. THE APPLICANT,OWNER.AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH.OR,BEFORE COMMENCEMENT OF THE WORK,WILL BECOME FAMILIAR
Wfl'H,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOS=INCLUDING OSHA REGULATION%
GL e. SM, 52$ CMR 7.N d sq,. AND ANY APPLICABLE MUNICIPAL ORDINANCES. BY-LAWS AND
REGLIATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT LSSVED FOR
SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WT'H CONDTIONS SET ming
BETON
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THR
EXCAVATOR TO UNDERTAKE SUCH WORE ON THE PROPRRFY OF TRE OWNER. AND ALSO, FOR THE
DURATION OF CONSTRUCTION. AUTI ORIUE! PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND mita 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
MVNK WALJTT IN CONNECTION mania PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT LIMITED TO ENFORCING THE EEQUUMMENTS OF STATE LAW AND CONDITIONS OF
THIS PERMIT.UISPEC77ONS 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 TlIFREWnn INCLUDING POLICE DETAILS AND MUER REMEDIAL MEASURES DEEMED
NECESSARY BY THE MUNICWALTY.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND.
. INDEMNIFY.AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF T'S AGENTS AND EMPLOYEES FROM
ANY AND ALL LTABILTTY,CAUSES OR ACTION,COSTS,AND EXPENSES RESULTING FROM OR ARISING OUT
OF ANY INJURY, DEATH, LASS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMT,
APP�[C+NNi'S[G� ���� �
� TUIty
A9f�,�'e// DATE 10/30/18
EXC VATOR SIGNATURE(IF DIFFERENT)
Same
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
Creme Ptz4rix DALES 10/30/18
he CEL/fwp a—Ds.et write belt
PtJtZI��APFROno BY Ali
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