HomeMy WebLinkAboutTR-19-3338 ••'`
*pr ,.aR TOWN OF YARMOUTH
3.3
BcA7 l- Iq-C038L
. '44' BUILDING DEPARTMENT Permit Number
p •' . °.g y 1146 Route 28,South Yarmouth,MA 02664
tat_M:: , .2 508-398.2231 ext. 1261 Fax 508-398-0836 Date Issued
• Expiration Date ,
$50.00
TRENCH PERMIT
Pursuant to C.L.c.82A §1 and 520 CMR 7.00 et seq.(as amended)
TH3 PERMIT MUST BE FULLY COMPUTED PRIOR TO CONSIDERATTON
Naar of Applicant f!aul C cnar�•Mn Piton* Cell
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bz513 Q,ou\sti
City/Toot. MA ZIP
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Nan of Excavator if different from applicant) Phone - Ceu
Street Address 70
City/Towel MA ZIP
Naar of Ownerls)of Property W °�v Prop.t,l,C Phalle Cell
Street Addrw
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CkylTown MA ZIP
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t ,acEOolp� I mp, I o(r32xc?
thher Contact I Perini*Fee Retched No l ) Yn(- )
Description.location and purpose of proposed tneeYn
Please describe the exact location of the proposed(retch and its purpose(*chide a dacrfp doe of what k(o`k intended)*
be laid la proposed trench lest plpa/nbk Ilan etc..)Please us*mine Ade If additional spank Beetled.
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RECEIVED
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set informsttnnof Insurer: .Dow\°rep 011,3eQU Ir�gjronce
Po Cba Iggp yc)tv,:a ct1A oatoot
Fniky pspintlnn Date: a i IQ 119
i DIs Sale F.
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IName at CuatpeteM Penes In defined by 520 CM*7.e21:
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License Credit S C, aA i• Expiration Duet �I31)17
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
WTTIL ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED.INCLUDING OSHA REGULATIONS,
C .:e. 112A„ 3111 CMR 7.01 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 THEREWTL•R 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 CONSIRUCT70N, AUTHORIZES PERSONS DULY APPOINTED BY111EMUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT'THE WORK FOR CONFORMITY WIIA THE
CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH WORE.
THE UNDERSIGNED)APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REIMBURSE TUE 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 REQVHtEMENIS OF STATE LAW AND CONDITIONS OF
THIS PERMITt,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 OTHE E 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 EME LOYEES 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 TILE WORK
CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNA
T + DATE /1/9o/i2
EXCAVATOR SIGNATURE(LF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATEe
Ter CBb/E'nr.a—De rt•rI4 k dies
11I VIZ BY
A
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