HomeMy WebLinkAboutBLDTR-19-002793 _•
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TOWN OF YARMOUTH 1 Bora--- 14-( -7 g
e o BUILDING DEPARTMENT i Permit Number 3
o del, '.4 y 1146 Route 28.South Yarmouth. MA 02664
'e �n I^ Z 508-398-2231 ext. 261 Fax 508-398-0836 ' Date Issued
/60 Expiration Date
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 ofApplicantyr ^ COMMA IyK 4J pnoPhene e 2 Cell
Stet Add lb
1/ .�gh CO
C own I MA ZIP IS I
41,4
Name of Excavator(if different from applicant) ` Phone Cell
Street Address miutG
Cityfrown I MA I ZIP
Name of Owners)of Property co 'a_NO lN Phone Cell
Street Address 14 Ro 7�C (.1`1 O/i )
C ty/Tolwn `�" 4 ! MA I ZIP
jv�7�eJ
Other Contact I Permh Fee Received No( ) Yes( )
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;pipeslable lines etc..)Please use reverse side if additional space is needed.
9e c— C or&ate RECEIVED
Fs' . 1
NOV 06 2018
BUILDING DEPARTMENT
BY:
4Name and Contact Information of Insurer
AiltE
Policy Expiration Date: —1 ' CCy�W
Dig Safe It:Pin l a 4(Y)%-o
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Name`orm�peett�enntt Person/(as dean 520 Of It
7./02):
1 of2
— — Masosdhosesa Hoisting Liens* __ q_
' Ilcenn Grades M E 1- Expiation Date. �!(� 'l�tJ
BY SIGNING THIS FORM.THE APPLICANT,OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF THE WORE,WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORE PROPOSER INCLUDING OSHA REGULATIONS.
C.L. e. S2A, 520 CMR 7.0$ et sett, AND ANY APPLICABLE MUNICIPAL ORDINANCE$ BY-LAWS AND
REGULATIONS AND THEY COVENANT AND AGREE THATALL WORE DONE UNDER THE PERMIT ISSUED FOR----_.`..
-----------SUCH WORE-WILL"COMPLY THEREWITH IN ALL RESPECTS AND wan THE CONDMONS SET FORTH
BELOW.
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR DURATIUNDERTAKE H WORK ON TIM PROPERTY OF TIM OWNER. AND ALSO. FOR In
ONOF CONSTRUCTION,AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORE 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 ID ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF
THIS PERMIT.INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH.AND MEASURES TAKEN BY THE
MUNICIPAU(TY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO
COMPLY THEREWfIH 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 AU.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.
APPLICANTS ATUURE— -
I Vight
' DATE
EXCAVATQE SIGNTURE IIF DIFFERENT)
DATE
OWNER'S NATURE(IF DIFFERENT)
DATES
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