HomeMy WebLinkAboutBLDTR-19-003702 it ''44TOWN OF YARRIOUTE1 I �R(�
` k " E , t,�o BUILDING DEPARTMENT i PerrnT[IV r /9" n 370
o .may • y 1146 Route 28, South Yarmouth, MA 02664
'�; -„ssi�"x 508-398-2231 ext. 261 Fax 508-398-0836 Date ISSlled
�� Expiration Date
DECEIVED
DEC 19 2018 TRENCH PERMIT
IT G DEPART?! t nt to G.L.c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
°Y --- PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION /0 L
Name
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(may��' �D
es Phone Cell
Street Address 2b „_ c.3-0<3 . a ? cl rig
City/Town MA ZIP -
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Name of Excavator(if different from applicant) Phone Cell
Street Address
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CitydTown MA ZIP -
Ne wnePro Phone Cell
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Street Address `
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Other Contact I Permit Fee Received No( ) Yes( )
Description,location and purpose of proposed trench:
Please describe the exact location of the proposed trench and its purpose(include a description of what is(or is intended)to
be laid In proposed trench(eg;pipes/cable lines etc..)Please use reverse side if additional space is needed.
S e—F f e-
Insurance Certificate(3----b3 as,,72��lC
Name and Contact Information of Insurer:
Policy Expiration Date: �(� ) it?
Dig Safe pr)1
Name of Competent Person(as defined by 520(MR 7.02):
fir.. ,`_ C / Afill Q • J
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Menge Gratin 2/9— Expiration Date /// ijo30
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.
Gd. c STA. 520 CMR 7.N d seq.. AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND
REGULATIONS AND THEY COVENANT AND AGREE THAT.ALLWORK.DONE-UNDER THE PERMIT ISSUED FOR-.--'-'--
-----------SUCH-WORK-WILL-COMPLY THEREWITH IN ALL RESPECTS AND WITH
BELOW. THE CONDTfLONS SET FORTE
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR UNDERTAKE SUCEI WORE ON THE PROPERTY OF THE OWNER. AND DURATION OF CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPAFOR THE
LITY TO
ENTER UPON THE PROPERTY TO MONTflR AND INSPECT THE WORE 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 THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE
MUNICIPALITY IN CONNECTION WITH THIS PEBMITAND THE WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT LIMITED TO ENFORCING TME 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 FA/LED TO
COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTTER REMEDIAL MEASURES DEEMED
NECESSARY BY THE MUNICIPALITY.
THE UNDERSIGNED APPLICANT.OWNER AND EXCAVATOR AGREE JOI
INDEMNIFY.AND HO HARMLESS THE MUNICIPALITY AND ALL OF ITS AYGENTSANDY TD FROMDEFENAND
ANY AND ALL LIABILITY,CAUSES OR ACTION.COSTS,AND EXPENSES RESULTING FROM EMPLOYEES
ARISINUT
OF ANY INJURY. DEATH, LOS,% OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APPLIC IC •
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-------- DATE /2-S-qj
EXCAVATOR SIGNATURE(IF DIFFERENT)
-
i- Weal
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE
Fee Cldfers e–D1 Si orbs S the Ise*
PERK OAPPROVEDBE '(
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