HomeMy WebLinkAboutBLDTR-19-3963 �,
.4>------ --.Y� TOWN OF YAi OU'l. .
4 Liti4.o BUILDIN -DEPARTMENT
NT Permit Number /3GDn- f%o3r163
of- '' ci 1146 Route 28.So tS'S'ErnGlie5.ALA 2664
••BBBiH\\ µ*., 41 508-398-2231 t. 6l f a,-508-398-0836: Date Issued
JAN 07 2019 . Expiration Date
By
DIPAIWL'r r $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
Name of Applicant Phone Cell
14 r ci< wE53
StreetAddre 774 l -a4Oq
6 pq-as-cr cr&c Lt pl-yr10.n A Email Address:
City/Town MA ZIP
etArmouto. - - - J ozaeo _-_ - --
Name of Excavator(if different from applicant) Phone Cell
(Crete L�.tc2
TOS- Szt-_3S` ( _-- -
Street Address
to SpNTudce L1t: A Email Address:
City/Town MA ZIP
t.u . 'fM2.Ak. U G 2d11
Name of Ownerls)of Property - Ptrorr Cell
Test1N CLAZIC - CA2o I.YN PMTr
Street Address
1 V (a-ruSeek ST. - Email Address:
City/form MA ZIP
Other Contact Permit Fee Received No( 1 Yes( )
Description,location and purpose of proposed trench:
Please describe the exact location of the proposed trench and its purpose(include a description of whet is(or is intended)to
be laid in proposed trench(eg;pipes/cable lines etc..)Please use reverse side if additional space is needed.
75 Burnet st - 5 f.,1sre c s 1 srev'1 - 6 An.Ace ItconbATTflq
C
•i
Insurance Certificate#: -
Name and Contact Information of Insurer:
1
Policy Expiration Date
Dig Safe!f:_
..( 2a IgSSoo765-9
/\1 Name or Competent Person las defined by 520 CMR 7.02):
1oft
A �i
.:
iNiame of Competent Person(as defined by 520 CMR 7.02):
NCcf< uj 3
Massachusetts Hoisting License#
H6 - 1.5-4 911 1 2 —3— 7
License Grade: Expiration Date:
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
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,
G.L. c. 82A, 520 CMR 7.00 et 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 RESPECTS AND WITH THE CONDITIONS SET FORTH
BELOW.
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR TO UNDERTAIM 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 GOVERING 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 PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING BUT 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 REMEDI.AL MEASURES DEEMED
NECESSARY BY THE MUNICIPALITY.
THE 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
OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNATURE
DATE / '7—(`7
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE / 7-/�1
OWNER'S SIGNATURE(IF D1FFIJRENT)
DATE:
For City/Town use±-D6 not yr to in this section A ?'
PEHIc TF AY FROVED BY ' r, Application Fee
.(P��1�. bonvnonweann m massacnuseus
iW, Division of Professional Licensure
Hoistin\ig Engineer Lai k 5-04, 165-1
HE-156911 . Expires: 12/03/2020
NICK J WEBB i'
6 PATRIOT CIRCLE 1x'
PLYMOUTH MA 02360 ` ` '
Commissioner L
•
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A