BLDTR-19-003580 ,i' TOWN OF YARMOUTH
�, of• q
' 4'• R'S' BUILDING DEPARTMENT Permit NuJ‘1D7 15'� 3SYl
0
p ^,,t'�j'GQ 4 1146 Route 28,South Yarmouth,MA 02664
? , I , 4 508.398.2231 ext. -Fax-508-398-0836--.•,. -Date Issued
` `--w. RECEIVEDI
xpiration Date
DEC 122018 $50.00
PI III_DING DEPARTMENT
Pursuant to G.L.c.112A 11 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
resent of Applicant 'Paul C. Chari-'t r� Phan Ce8
4treatCAddtces�a be It Scv' cc.S trC. 50&775-a6a5
t6o AouAe
Cityll'owa HA ZIP
`laciwkitti 1 oato7
Naw of Excavator(if ditTerem from applicant? Phone Cel
Street Address
City/Town MA I ZIP
Naw of Ownertst of Property `Jtle°Ao. cr pe Ca
Strea!Addrw 1 al-aab-Cv(tCCR
9,11• fl 0- Lk.
CkyITown MA ZIP
(fiver Contact J Permit Fa Received No( ) Yes( )
Description,kcatloa and purpose of propoad treacles
Please describe the exact location of the proposed barb and its purpose(Include•descrtptka of what is for Is Intended)to
be laid In proposed trench(e;:pipealable Uses etc..;Please use reverse vide if addttlond space Is needevl .
c/-etiet a. /‘Z6>ere// / Pi 0"P4 r 0-f /G'ro/rrpgy
1neW4n01l'ertifkIIt »t ^-1pU()Jr/I.;0 cli3c1q4►g
Mame sad CoMart Inforrnsebn of Insurer. Dow\°nc, 4.' O'Neet Sn&urc\cce
Po tba, IQQG ioin- s mR Gaupt
'dill('FtpinUMn Dater 511-allq ...
D``Oaf`h
I
! Nihau et Competent Penes t as defined by 520 C'MR 7.021.1
1 of2
TL..aatuertt.lialstIng l.wens.r 1-,E 02:)a R3-
unr»Grades t C, aA " Pr Espintkwe Data 513%1/5.
BY SIGNING THD FORM.THE APPLICANT, OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
TEAT 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.
CL. a 821, SIt CMR 7.01 a 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 TIIEREWTTH 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, AI THORI7Z3 PERSONS DULY APPOINTED BY TILE 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 TEE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE
MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING RUT 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.
THIP UNDERSIGNED APPLICANT.OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDEMNIFY,AND HOLD HARMLESS TILE 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 TITIS PERMIT.
APPLICANT SIGNAT URY
e.___,.____,........ ��- DATE /2/z4 .3p
EXCAVATOR SIGNATURE al DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
Fe
nth, 4.bf ,n--Du wt ere.le glib
unsoinit
2 of 2