HomeMy WebLinkAboutBLDTR-19-003135 oF 'gk TOWN OF YARMOUTH 1 dby11_►q-.b(o3I3c
° tt t �c BUILDING DEPARTMENT Permit Number
• p - ' C 1146 Route 28,South Yarmouth,MA 02664
N ,', . 2 508-398-2231 ext. 1261 Fax 508-398.0836 Date Issued
tr
• rc. -
$50.00
TRENCH PERMIT
Pursuant to G.L. c. 82A §I and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant Rpta errs- 8 . QC C O 4 Phone Cea
Streetddrees
a 1 G t ( 3esVer.j
t /townP
rA94 .01N Imet ZIaa6CI
Name of Exeae toe(if different from applicant) Phone
- CuYT1 S Cell
Street Add •
¶r 1‘)c.fie CLreel& `111 Z3C--7q1-19
Cityftown I MAZIP
3QAcQtu\ck to k
Name of Owner stof Property ��
,� D 1•//•J CeB
Street Address
1lW &lANUP'
City/Town MA I ZIP
Other Contact I Permit Fee Received No( 1 Yes( )
Description,location and purpose of proposed tench:
Please describe the exact trench
of the proposed trench and its purpose(Include a description of what fa(or Is Intended)to
be Ilaid In rn e6; ps/cable line etc..)Please use reverse side if additional s
11 �U)11U�/J 1Z� Cr� of F�&c �N,STQV1 %Paepei/reededc1�
t'1 t1�G `�Nc2/n
RECEIVED
NOV•
20 2018
MT epic I
i Insurance Certifkate ft __
Name and Contact Information of Insurer
2N-ParA -nb nU mc>,
7 Policy Erpintion Dates 1 '
•
Dig Safe N: L' O _ao
ao l�—
Name of Competent Person tas defined by 520 CMR/AM:
inix z✓ EldreARrik
I of
• r
b!a atheseib Heisting theme 14
(03.1/453 [D
License Grdet e.� V i Expiration Date: C u 11,ao
BY SIGNING THIS FORM,THE APPLICANT,OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WTI1I,OR,BEFORE COMMENCEMENT OF THE WORK,WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS.
GL e. 12A, 521 CMR 7.01 it se¢, 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 ANT)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.
TBE 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 AU.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 SIG �J ARE
7 .14.' L���� DATE IV/
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE \\,\`
40
•
OWNER', IGNATU ' IF DIFFERENT)
' t� ' V► DATE: it/a0[/
S
Fee ow.„.err—Da not era hi SI
roan APFIMw=sv Applauds res•
CONDTJ1ONS 01=AW
2 of 2