HomeMy WebLinkAboutBLDTR-19-002551 11 1C14, 11 .04HIVI, ,OVOJtloVOJo fi I/ L
Term TOOF YARMOUTH 6 772-fro s sl
• ., i' e° BUILDING DEPARTMENT Permit Num er
° - VS °_ 1146 Route 28,South Yarmouth,MA 02664
H 7 508-398.2231 ext.1261 Fax 508.398-0836 f Date Issued
Expiration Date
• $50.00
TRENCH PERMIT
Pursuant to G.L.c.82A§1 and 520 CMR 7.00 et seq.(as amended)
TITS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant So S ett-Ma Phone
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earnan +ccr�o�}%nCj �.LL 50g L{3a X565 1 4430 6L4za
Street Address
‘,5 SPeckk. WEmail Address:S(xat.vrAnexcczD,tonqc@inoirn'a .col
City!Town A ZIP
NGrw4ch oaeAs
Nan of Excavator(if different front applicant) Phone Cel
Street Address Some.
Email Address:
City/Town I MA ZIP
Name of Owner$)of Property I'1 1 A tJk - Phone Cell
Street Addren d c,/v„ T
Cv 1616 e. ,W1� Email Address:
City/Town � MA ZIP
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Other onaet I Permit Fee Received No( ) Yes!
Description,loatioa and purpose of propoud trench:
Please describe the exact location of the proposed trench and its purpose(Include a description of what is(oris intended)to
be laid ha proposal trench(eg;pipes/able lines etc..)Please ute reverse aide if addition!space Is needed.
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BUILDING DEPARTMENT
NameandcerdtkateMt `_, cC,_5oo - 5oo8`�, -aoiQ BV _� — —
I Name and Contact Information of Insurer.
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: Polley Expiration Dote:
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Nome of Competent Penne pas defined by 520 C:MR 7A2;:
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' Ll ms Grades o1 R Ervin:on Date I 1 /a5 /a019
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 FAMILL**
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS.
C.I.. e. S2*, 526 CMR tee et seq. AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-TAWS-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 WTTH 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 TIDE PROPERTY TO MONITOR AND INSPECT 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
REMOURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE
MUNR:IPAUIY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
[Nett-WHIG BUT NOT LIMITED TO ENFORCING THE REQUHwEHBKtS or STATE LAW AND CONDITIONS OF
THIS PERMIT,IVSIPEC IONS MADE TO ASSURE COMPLIANCE TFIPR WITH.AND MEASURES TAKEN BY THE
MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO
COMPLY THEREWITH INCLUDING POLICE DETAIS AND OTHER REMEDIAL MEASURES DEEMED
NECESSARY BY THE MUNICIPALITY.
TILS UNDERSIGNED APPLICANT.OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
IVDBMNIfY,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 THE .WORK
CONDUCTED UNDER THIS PERMIT.
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