HomeMy WebLinkAboutTR-19-3878 tieoF ,.aR TOWN OF YARMOUTH
' }., o BUILDING DEPARTMENT Permit Numb t72-5-0 0 311'71-
• p�'W •�s y 1146 Route 28,South Yarmouth,MA 02664
J Y •. / . .T 508.398.2231 ext. 1261 Fax 508-398-0836 Date Issued
Expiration Date
$50.00
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
Nana of Applicant QuAllC cc\ac\-tn Phan* Cell
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City/Town1 MA ZIP
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Duaiption,louder and purport of proposed trench:
be
Plow describe the exact location of tht propaed(cash and its pis/poet tiachds a description et visa*k(or k intended)its
maid la proposed trench(tit pipealnbk lion etc..)Pkss w rattles rids if addidand spats k titeckd. Y^.
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mans of Competent Perron las tk(Ined try$20 C'MR 1.02):
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ILicense Grades 1A,�R
CJ Expiration Date 5/
BY SIGNING THIS FORM.THE APPLICANT, OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR W !,OR.BEFORE COMMENCEMENT OF THE WORK,WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORE PROPOSED,INCLUDING OSHA REGULATIONS,
G.L. e. 12A. 5241 CMR 7.041 d seq., AND ANY APP'ICABLE MUNICIPAL ORDINANCES, BY-LAWS AND
RBGLIXflONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR
SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH TILE CONDITIONS SET FORTH
BELOW.
•
THE UNDERSIGNED OWNER AUTHORIZES THA; 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 MUNICIPALTIY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT TBE WORK FOR CONFORMITY WITH THE
CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH WORE.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REIMBURSE THE MUNIC>WALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY TUE
MUNICIPALITY IN CONNECTION WITS THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT LIMITED TO ENFORCING THE REQVIREMENIg OF STATE LAW AND CONDITIONS OF
THIS PERMIT.INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH.AND MEASURES TAKEN BY TRE
MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS TAILED TO
COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEM/TD
NECESSARY BY THE MUNICLPAl1TY. `
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
LNDESINJY,AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEBs 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
DATE / ,PP/c4"
EXCAVATOR SIGNATURE(IF DIFFERENT)
DAlE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
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