HomeMy WebLinkAboutBLDTR-19-003351 •
o.YaR TOWN OF YARMOUTH 7��
3.S/
"To BUILDING DEPARTMENT Permit Numbs a 7Q'79-c
y 1146 Route 28,South Yarmouth, MA 02664
508.398-2231 ext. 1261 Fax 508-398-0836 Date Issued
•
Expiration Date
$50.00
TRENCH PERMIT
Pursuant to G.L.c. SM §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Nan of Applicant Phone
Ready Rooter Excavating Cell
Street Address PO Box 89 508-888-6055 508-509-0802
City/Town MA ZIP
Forestdale 02644
Nan of Emanate add/trent from applicant) Phone l'ea
Street Address
City/Town M ZIP
Name of Owners)ofPnpe Tim Roche Phone Cell
Street Address 78 Taft Road 617-733-3769
Clty/1'own MA ZIP
West Yarmouth I 02673
Other Contact f Permit Fee Rented No( ) Yes(X,
Description,location and purpose of proposed trench:
Please (describe the exact location of the proposed trench and its purpose(Include a deacripten d what b(or Is intended)to
be laid proposed trench leg;pipesah4lines etc..)Pease use reverse side If • .
Install new Title 5 septic systen in rear of property. tree
aG 1 V t= p +
DEC 03
3 2018
/4" ""/ RTM ,. Pl/j •
I 9 J
Insurance Certiikate et
WC5-31 S-390198-18
Name sod Contact Information of!myna
Liberty Mutual Insurance
PO Box 2027 Keene, NH 03431-2027
Polley F.epintlon Data 04/15/2019 _.._
net s./.N: 2018- Li ct OoC?S`&
Nome of Competent Perms tad defined by S20 I.MR).e21:
Patrick Sullivan
1 of 2
Mssbschusetts Hoisting License I HE-144345
•
•
Venue Grades 2C 1A •.Expiration Date: 11/05/19
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
WTH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED.INCLUDING OSHA REGULATIONS,
GL e. $2A, 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 WORE ON TIRE 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 WIH THE
CONDmONS ATTACHED HERETO AND THIS 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 THEREWrrH 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
OP ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNATU
DATE (2( 3 ( ((
EXCAVATOR SIGNATURE([F DIFFERENT)
DATE
OWNER'SS (IFDIFFERENT)
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