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Home My WebLink AboutTR-19-2728 'fi , TOWN OF YARMOUTH 5Q'Sl 2 2, rq -Ott1.1a 2 " t. YAR BUILDING DEPARTMENT Permit Number of , �g,_ t 1146 Route 28,South Yarmouth,MA 02664 Date Issued .., „,..: „ , A'. 508-398-2231 ext.1261 Fax 508-398-0836 : :- 4,, 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 A(.(. cos"- Seer G t t-C Phone 5c8 i'/ -qua Cell Cop 757-1117 Street Addreys Go/ g am- Zk Email Address: a//cell. cc/4i c e p40 1 CAA- City/Town MA ZIP 0- Val ✓ 07415 Name of 17091‘Excavat r(if different from applicant) Phone Cell E'prPJs/ -t 11n-257-738v Street Address �/ Zaiset fr.( ,4.rur� I(7 Email Address: Cityfrown MA ZIP /wt.ei ✓ 016YS Name of Owners)of Property /1Phone Cell StiekAddediesa SV Cd ataro° Gq3 - 57'f3 \ 9 f/r9r0v-e_ S�rte7 Email Address: — ) Cit frowni./ ..-' ZIP MAW-hr.' k Gf ObOtfO. Other Contact I Permit Fee Received No( I Yes(yr— 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 for Is intended)to be laid in proposed trench(eg;pipes/cable lines etc..)Please use reverse side if additional space Is needed. n /N9 /41:m1 /Soo Gel SrfAe -0 At., Ce.,u2' p-epic a".b/ CMu-t 4 C4'.3 "-' frtr3 Atli a ( 4Ih IS : 13 A7,4-4 A - So - Y rt✓A r144-. i Insurance Certificate k: &cb Z lid - O G ;37.0.5-- 4 -/t _ a I Name and Contact Information of Insurer. 1N31,111:Vd30 ONIalif u 4o /t,vl4 rt tom..! /ays.rn..a 6k-7.1- (Svu) 832 -4931 Policy Expiration Date: 9//F//' OZ 50 IDig See fig Sol $ - *SD —7-14,0 Name�of Competent Person las defined by 520(MR 7.e2): -G n ' 3 d t; dr I I it?ii-C /tin t am-04 1 oft -,,. Name of Competent Person(as defined by 520 CMR 7.02): 1> iris fir ' r'IAt/at-!O, Massachusetts Hoisting License# /r Ph 9?7 License Grade: 1-A" IG Expiration Date: 7/2// q 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,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 THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH 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 THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE 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 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 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. APPLICANT SIGNA DATE EXCAVATOR SIGN U. . (IF D I AlAI DATE �rJif N1) Sriot Itet /�� OWNER'S SIGNATTU' (IF® , DIFFERENT) aA -ca -41J K/ DATE: �I1/ S � a a":�.. t _,F.•"`r . air, ".:1 -'G '! :- art e...FOC lty/TOWR use'--Dnitottitein this SeetiMt&*c :PERMTEAPPROVEDBY e g' ' ' AFPIicationEeei t r3;r`rf',4rr r s r r';, ?EIZMITTING'AU°THQRITX = ` .�,�. .. � .i 4Dat� '' , � ? • • The Commonwealth of Massachusetts Q =, _�!t Department of Industrial Accidents 5 :nl= 1 Congress Street, Suite 100 _l Boston, MA 02114-2017 :c c,:o www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information r Please Print Legibly Name (Business/Organization/Individual): At( COP Stekt LLC Address: (o/f3 e% ZQ- A City/State/Zip: Wes r Y,orm�{{/ Phone #: cog 171 -(f zdD Are you an employer?Check the appropriate box: - Type of project(required): i am a employer with Vi employees(full and/or part-time).* 7. 0 New construction 2.0i am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3. Iamahomeownerallorkm elf 9. ❑Demolition ❑ doing myself[No workers'comp.insurance required.] 10 ❑Building addition 4.❑i am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance,: 6.0 We are a corporation and its officers have exercised their right of exemption per MOL c. 14. Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. �A[ Insurance Company Name: AGC 144-Vd( w� Policy#or Self-ins.Lie.#: (e S/0 2V6 - O 6 33tot-4-/t Expiration Date: Y SY•• `,e9//B'/f Job Site Address: /3 Av4Z/I- t' City/State/Zip: cn,iic& I't' 7-6 7> Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: it/l�/ tt4tGw-3 Date: /l/Se/if phone#: (COt) 171 - tftO'D Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 4 h • VDAC CHUBB' WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6562UB-0633205-A-18) RENEWAL OF (6562UB-0G33205-A-17) INSURER: ACE AMERICAN INSURANCE COMPANY NCCI CO CODE: 12165 1. INSURED: PRODUCER: ALL CAPE SEPTIC LLC MARSHALL K LOVELETTE INS 618 ROUTE 28 396 MAIN ST WEST YARMOUTH MA 02673 WEST YARMOUTH MA 02673 Insured Is A LIMITED LIABILITY COMPANY Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period Is from 09-18-18 to 09-18-19 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s)listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work In each state listed In item 3.A. The limits of our liability under Part Two are: k Bodily Injury by Accident: $ 100000 Each Accident ( Bodily Injury by Disease: $ 500000 Policy Limit Bodily Injury by Disease: $ 100000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, If any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B m=_ D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE o= 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating cram= Plans. All required information Is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 09-24-18 WC ST ASSIGN: MA OFFICE: RMD CHUBB 24M PRODUCER: MARSHALL K LOVELETTE INS 78BJB 007452