HomeMy WebLinkAboutBLDTR-19-003578 • TOWN OF YARMOUTH
'3 {'.4 ,YAR'� BUILDING DEPARTMENT Permit Nun?ber "4
p . iv $ C 1146 Route 28,South Yarmouth,MA 02664
V' ,,*:r h 4 508.398.2231 ext..1261.Cax.508-3980836 Date Issued`�`�° 4� RECEIVED
1
Expiration Date ,
DEC 12 20181"---
50.00
e��`'T C TPEt S IT
Pursuant to G.L. c. 82A §1 and 3Z0 Chi 7.00 et seq.(as amended)
TNLf PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Naw of Applicant SevPhoebe
08 Celltoe, ees =rC• 55-asa5!lttre'ldde.e
City/Town MA _II ZIP
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Nan of Esnratoc Iif different front eppieant) Phare CIO '
Sheet Addrn, ,
Cltylrown MA I ZIP
Naw of Ownerys)of Property Phone Cell
strew Addre.e)e`in L'u -1%1- t15-tci
153 Freeccpn O,d
CkyA'own LMA ZIP
x-.1accMr/1OLo75
Other Contact I Permit Fee Reedred No t ) Yes t 1
Description,loeatlouand purpose of proposed treaehr
Please describe the tact location of the proposed trench and its purpose(Include a description of what Is(or to Intended)es
be laid In proposed trench lett pitmicabk lines rte..;Please we reverse side If eddidonat space Is needed.
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IrounnaCertificate Mt —1n „MEF51.-A(3rle:0
1 Nen end Contact Inforenstbn of insurers .Oow\`,nG A' OiNe41 Ir rcrsa1
1 Po 23c. 14Q0 Vsryonn°s mP oatroi
Policy F_vpinekonDarr, $l i.a))(11
Dig Saf.rt a0, 2 — L11-1015ILI
I ,Nems of CumpeteM Perios las defend by$20(Mi 7Alpt
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Mfaaadroesttn licking Limit.$ N E 0$a Rb-7
. LNeerM Grades I C2 ac , a Expiration Date: 0/ttt I l9
BY SIGNING TIDS FORM. THE APPLICANT, OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH.OR,BEFORE COMMENCEMENT OF THE WORK,WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED.INCLUDING OSHA REGULATIONS.
G.L. t. t2A. 32$ CMI 7.011 it it,, AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY.L.AWS AND
REGLLATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMTI ISSUED FOR
SUCH WORE WILL COMPLY TILEREWLTH IN ALL RESPECTS AND VETTE! THE CONDTRONS SILT FORTS
BELOW.
THE,UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY MR THE PERMIT AND TUE
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 won.
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 THEREUNDEJI,
INCLUDING BUT NOT LIMITED TO ENFORCING THE REQVIREMEN13 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 IIAS FAILED TO
COMPLY THEREWITH INCLUDING POLICK DETAILS AND OTHER REMEDIAL MEASURES DISMZD
NECflARY BY THE MUNICIPALITY.
TRE 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 SIGMA
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EXCAVATOR SIGNATURE LIF DIFFERENT)
DATE'
OWNER'S SIGNATURE(IF DIFFERENT)
DATES
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