HomeMy WebLinkAboutBLDTR-19-002666 iiR . TOWN OF YARMOUTH p0-1 G�
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BUILDING DEPARTMENT7p�Permit Number �i4c.
11.6 Route 28, South Yarmouth, MA 02664 ! Date Issued
+ ...Y508-398-2231 ext. 261 Fax 508-398-0836
's= Expiration Date
TRENCH PERMIT
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
TIILS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant it3orLau. COAck'UCWC,Yl Zr7C. Phone Cell
Street Address y 1-
5 ncLe'l psi . sis- 771 - ! 39 /q
City/Town . MA ZIP •
Mct�rs\'tnu) RILL- c>aco`/K
Name of Excavator(if different from applicant) Phone Cell
Street Address
City/Town MA ' ZIP '
Name of Owner(s)of Property0 i an¢,CUcvno J'2 Phone Cell
Street Address%s. szirthAt.c c ` S'UFS - 3(o'd - S a,(5
City/Town MA ZIP
10.cvYo fol- 0ac.9S
Other Contact I Permit Fee Received No( ) Yes( )
Description,location and purpose of proposed trench: tele pig., ckgxit,ti, - jaXIfi,IC a4J
Please describe the exact location of the proposed trench andits 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.
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Insurance Certificate it: CPA Qpt/qL8 330
Pat.00 60148 330
Name and Contact Information of Insurer:
Spotatt 51-One; t,.Lrsunnnt.es- Sog -'V25-/630 fNetrIA Ncalrip%)
Policy Expiration Date: Mailer\ n 'do19
Dig Safe it: acts (NO`d(o.3 Intel,% '7:3op w^ _.
RFCpCt'y
F I V E
Name of Competent Person(as defined by 520 MMR 7.02): I
S 1( tto 1140V 022018
BUILDING DEPARTMENT.
By
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.ousetts Hoisting License# /3G yap_
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License Gracie: 4 Expiration Date:
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
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED;INCLUDINCOSHK REGULATIONS,
G.L. e. 82A, 520 CMR 7.00 et 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.
TIM 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 CONSTRUCTIION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE 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
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 t HEREWITH,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 OTHER 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 THE WORK
CONDUCTED UNDER THIS PERMIT.
APPLICAN .IG . . '
DATE l/// /l F—
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EXC TO t -1 ATURE at : i' RENT)
c...../ I DATE /O/3 i !t
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Ott SIGN RE(IF DIFFERENT)
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For CihlTowet use—Do clot write id tads'sectittno ' ; .
PER".I IF.APIPROVED ny i ! Apioleemoion Fem
PERMITITNt AUTHORITY-.• :• v• Dote-.. . , • :'• ,,,
.
CO ITIONS OF APYRONAL.
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