HomeMy WebLinkAboutTR-19-3083 1 BTS—\q -4_7)30E?
- - t•YAk TOWN OF YARAIOUTH
;' So` BUILDING DEPARTMENT Permit Number
r eh Sf44 y 1146 Route 28, South Yarmouth, MA 02664 1
l •_' 508-398-2231 ext. 261 Fax 508-398-0836 Date Issued
Expiration R
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[ctit19201TRENCH PERMIT qL0-3_1!Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as : avatar DEPARTMENT
TIM PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant eiterk eh 1 ids---fr. , Phone Cell
rem Afifinnt 51gSi821q9 5b85-09 6,1,1 C°
Cityffownt. Y MA ZIP
S.ben()IS 026C0
Name of Excavator(if different from applicant) Phone Cell
Street Address
City/Town MA ZIP
Name of Owner(s)of Property Phone Cell
Street Address
133 [did 1S12d
Cityffown MA ZIP
W A/ar��w1-h (2 2073
Other Contact I Permit Fee Received No( ) Yes( )
Description,location and purpose of proposed trench:
Please describe the exact location atilt proposed trench and its purpose(include a description of what is(or is intended)to
be laid in proposed trench(eg;pipes/cabk lines etc..)Please use reverse side if additional space is needed.
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Insurance Certificate ft:
n PA- o : cc "i SD2-1 V V C 4 031& / (031s
Name and Contact Information of Insurer:
1 )6 Millet i &"75?
Policy Expiration Date: Ilio
Dig Sale If: ap1s !o l ei (q
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Name of Competent Person(as`sddeffiineded by`520 CMR 77.02):
Gh n s for ti r Lilticistas
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Massachusetts Hoisting License# 14 L 101 -77 q aI I 161
License Grades I V 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,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 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 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.
ti's I 0 DATE ///// /i(r
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
O o ' R . / AnJI (IF DIFFERENT)
DATE: I
- For City/Ton ems—Da not write it this section
PERMIT APPROVED BY . Appieatlas Fa.,
PERMI7TINGAUTHOYfl'Y,; der ,
CONDITIONS O/APPROVAL.:.
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