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HomeMy WebLinkAboutBLDTR-19-003438 • a u��gRb TOWN OF YARMOUTH nZ�M ' �✓x{�J� !2 BUILDING DEPARTMENT Permit Number it; 1511 1146 Route 28, South Yarmouth. SIA 02664 IO.'\-; s" `08-398-2231 ext. 261 Fax 508-398-0836 Date Issued Expiration Date TRENCH PERMIT Pursuant to G.L.c.82A §1 and 520 CMR 7.00 et seq.(as amended) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Appiiant I I Street Address a3 I�ha�r $it 30`- (2337 City/Town MA ZIP art- 01411 eoce— oa. os Name of Excavator(if different from applicant) Phone Cell Street Address City/Town MA 1 ZIP Name of Owners) Phone of Property Cell Street Address D0 M I O EO L'1 k`d.- a01 ^3 0-'I3-Sca 17 (dell of- ki-es- Clty/fownMA ' ZIP ogot _ Other Contact 1 Permit Fee Received No( ) Yes( 1 Description,location and purpose of proposed trench: Please describe the exact location of the proposed trench and its purpose(Include•description of whet Is(or Is intended)to be laid in proposed trench Leg:pipes/cable lines etc..)Please use reverse tide If additional space is needed. n linlW cam, RECEIVED f1aj `?l: 0 ''0 DE P.\Rrn4LNT insurance Certificate I: CG$DOSp pp 7C pat 19 Name and Contact Info_rm/ation of Insurer. Polies Expiration Date: i / Sate t ro lo13 Name of Competent Person las defined by 520 CMR 7.02): IA Mar(1 I oft /do' r _ l . Maswebosttts Hoisting MSS I 6 '-of i FA-yid,— Limit*Gude: " GoW.6'7.3 �'ratioti �` 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 wmi,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS, C.L. ct1A, SIO CMR 7.011 a 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 RFS?ECTS AND WTTI 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 ANDSEVERALY TO REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE ' MUNICIPALITY IN CONNECTION WITH THIS PERMITAND THE WORK CONDUCTED THEREUNDER, INCLUDING BLIT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDEMNS OF THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE T EREWITH,AND MEASURES TAKEN BY THE MUNICWALIT'Y TO PROTECT THE POETIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED NECESSARY BY THE MUNICIPAL/TY. THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND, INDEMNIFY,AND HOLD HARMLESS THE MUNICIPALITY AM)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. APPLICANT SIGNATURE DATE EXCAVATOR SIGNATURE(IF D i • s A. Ws ix ii . . 1.—S. a DATE I'I — G`t"—L� OWNER'S SIGNATURE(IF D I - • a bi MI1 tketati DATE: For lin?aisie on-Di tipt'Sante Poe seitiiw: PL7t�ITf.APPRA O\la1DY� $; . AI nMefn Itt\Df fl)%SOEAH7tOVAL. 2 of 2 • From:Central Fax Fax:(877)816.2158 To: ,.Fax: (508)362-6268 Page 2 of 2 12/15/2017 222 PM • REID&LA-01 THORNE A`OROe CERTIFICATE OF LIABILITY INSURANCE DATE12/15/WYYYY' 12!15/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED • REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT. If the certificate holder Is an ADDITIONAL INSURED,the pogcyges)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such eNnrdorsemeM(s). PRODUCER N2L1EACT Rogers S Gray Insurance Agency,Inc. PRONE FAz 434 Rte 134 /AIC,Ne Eft): I WC,Hai:(877)616-2158 South Dennis,MA 02660 iS'ofss:mailtrogersgray.com INSURER(S)AFFORDING COVERAGE NAIL INSURER A:ExcelslorInsurance Company 11045 INSURED NSURERB:Arbella Protection Insurance Company,Inc. 41360 Reid&Laurence Ellis dba Ellis Brothers Construction INSURER:Associated Employers Insurance Company 11104 23 Enterprise Rd,.P.O.Box 59 NSURERD: Yannouthport,MA 02675 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER; REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. /NSR ADOLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE /NSD WVD POLICY NUMBER (MMIDOIYYYYI (MMIDDNYW) - LIMITS A X COMMERCIAL GENERALUABIUTY EACH OCCURRENCE 1,000,000 CLAIMS-MADE a Ocam CBP9697130 03/01/2017 03!01/2018 PREaVaciF440Mg) S 100,000 IAEDEYP(Am ono Dotson) f 5,000 PERSONAL 6 ADV INJURY S 1,000,000 GENT AGGREGATE LIMIT APPLIESPER GENERAL AGGREGATE f ZOO OOT POLICY Li78f BLOC PRODUCTS-COMP/OP AGG S 2,000,000 I OTHER: S B AUTOMOBILE UAOILT' /CEOMaB gEDUSHGLE LIMIT f ANY AUTO _gg 102000260706 06109/2017 06/09/2018 BODILY INJURY(Pet smarm) S 250,004 AUTOSoNLY X rAIJJUS�gMIJ1OSU1EEp BODILY INJURY(Per accident) S 500,000 X ALTOS ONLY X A3TOiVNLY IPmPEOasnO AGE s 100,000 $ _ UMBRELLA LIAB - OCCUR EACH OCCURRENCE _S EXCESS UAB CLAIMS-MADE - AGGREGATE f _ DEO RETENTIONS f C WORKERS COMPENSATION I PER I I OTH- ANDEMPLOYERS UABILITY STAME R /kilt PROPRIETOR/PARTNER/EXECUTIVE YIN WCC50050007062017A 12/03/2017 12/03/2018 100,000 (Mandatory In NH) U1i09 . n NIA El.EACH SE-EAST S 100,000 E L.DISEASE•EA EMPLOYEE f nEySCdesTAbe undm 500,000 OESCRIPTI011 OF OPERATIONS below EL.DISEASE•POLICY LIMIT f . DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101 Additional Remarks Schedule,sow be attached x mon space Is required) Certificate holder is an additional insured under General liability for on-going operations when required by written contract or agreement. • CERTIFICATE HOLDER CANCELLATION • SHOULD ANY OP THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1146 Route, .arm ACCORDANCE WITH THE POLICY PROVISIONS. 2South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. • The ACORD name and logo are registered marks of ACORD •• Commonwealth of Massachusetts V. Department of Public Safety License: HE-028673 Hoisting Engineer LAURENCE F ELLS JR 8NORTH ST DENNISPORT MA 02839 12/ l.a0 l7na -- Expiration: • //Commissioner 12/3012018 • Hoisting Engineer Restricted to: HE-2A-Excavators OIG SAFE Call Center.(888)344-7233 In case of accident call:(808)820-1444 DPS Licensing Information visit:W W W,MASS.GOV/DPS �,