HomeMy WebLinkAboutTR-19-2910 Nov/01/2018 6:10:28 AM Marriott's Ocean Pointe 561-882-3001
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s_ BUILDING DEPARTMENT • 'Permit Number
.- �.y:e•4t: 91‘i 1146 ante 28,South Yarmouth,MA 02664 i
"'"-I1,', 2�' 508.398.2231 est.1261 Fn 50&398.0836 I Data Issued •
' `t Expiration Date
$50.00 •
TRENCH PERMIT •
Pursuant to G.L..c,82A§1 and 520 CMR 7.00 et acq.(aa amended) •
• THIS PERMIT MUST BE FULLY COMPLETED PRIORTO CONSIDERATION •
Nome of Applicant (dig i I- CA:1S CLICd--I•on � Phan u S ' (635 Cell 5ed.! S �.No
Street Address n 0 iarmo'nd S rYwth . Email Address:cliqy:(co:.C 9 also a•cc M
City/Town MA ZIP
C• Deanis Mk OZllo(o0 _ • •
Name ofExo.ntertit diffarentfrom Applicant) • Phone ' Cell
Setts(Address •
Email Address: •
City/Town MA TM
•
Name of Ownap: of Pr ' Phone • Ceit •
Pa [3. 6t3Dree ` $O? 'di 4100-1 •
Street Address `PMf r•1'r r 1
4rikhiet5 W '- Email AddresstOLjtsbr.ee 0comato•mi.
Cay/Town MA ZIP R
S• iitaroulb frlf1 094( Li .
_,Other Contact I Permit Fee Received No l ) Yes t / .
Description,location and purpose of propend peach:
Please describe the exact location of the proposed tramp and its purpose(include tt descripetoo of what is(or b Intended)to
be laid In proposed trench(eg;plpeafeable Una ale.)Please we oven side If additional space Is needed
opgrexeke. C s4( R[ NOV13
E C E I V E D •
• 2018
BUILDING D _PARTMENT
By •
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Insurance Gatif cafe tit CO al-13q6(51-.‘
1Vane and Contact information of Insurers
6'451-atm cleacs. insurance — So ()rasped 54. t' edi•K rn /VIA, 0'3x53
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: Policy Expiration Date:
rDl$SLelh o�01c t 00 3 OLt7
Nene of Competent Person tea defined by 510 CIR7.0li:
•
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Nov/01/2018 6:10:28 AM Marriott's Ocean Pointe 561-882-3001 2/2
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Name of Competent Person(as deemed by 520 CMR 7.02):
Massachusetts Hoisting License#
HE. - 1-1011(4-1
LfeenseCrade: 2 /}/I C Expiration Data t 0 r 3 ((c
BY SIGN/NG THL4 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,
GG c. 82A, 520 CMR 7.00 et sack AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND
REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER TBE PERMIT ISSUED FOR
SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITS THE CONDITIONS SET FORTH
BELOW.
THE UNDERSIGNED OWNER AUTHORIZES TIM APPTSCANT 'TO APPLY FOR THE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WOES 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 TM; 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 PEEMIT 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 PALM TO
COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DFEMFJ)
NECESSARYBY THE MUNICPALITY.
THE UNDERSIGNED APPLICANT,OWNER'AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDEMNIFY,AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF TTS 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.
AP/��� A '�,SIG A •
s DATE //— /‘,
•
EXCA SIGNATURE(IF DIFFERENT)
------ _DATE /
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
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