HomeMy WebLinkAboutTR-19-4078 •
TOWN OF YARMOUTH
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IZTR-Iii-1 D7�t o BUILDING DEPARTMENT . Permit Numberi vg y 1146 Route 28,South Yarmouth,MA 02664
_2• 508-398.2231 ext. 1261 Fax 508-398.0836 Date Issued
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$50.00
TRENCH PERMIT
Pursuant to G.L.c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
TIRS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Naar of Applicant Kolobrs8 .�j
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Street Addrees
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City/Town • ZIP
Name of Eacavp{or(if dWTermt from applicant)
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Street Address r /0•A)4 �2 sti r-C %-b (0.-- 191q
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City/Town 0 MA I ZIP
Naar of Ownerls)of Property a . Phone
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sheet Address 510_q _C5G`O
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Other Contact 1 Permit Fee Received No
Description,location and purpose of proposed trench: ( ) Yes( 1
Please describe the exact location of the proposed trench and its purpose(Include a description of what S(or Is Intended)to
be laid In proposed trench les;pipes/cable n lines etc.)Please use reverie tide If additional space Is needed.
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RECEtVEDI
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I JAN 112019
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Name of Competent Person las defined by 520„(5::741&
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Hds:ing Lkmtce o 1.1 €_. 1 n a.(035/4940
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LEMUR Cade: 01'fi Expiration Date:
BY SIGNING THIS FORM. THE APPLICANT.OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMHJAR WITH,OR,BEFORE COMMENCEMENT OF THE WORK.WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS.
CJ_ r. $2A, 510 CMR 7.01 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 N 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, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT ME 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 THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE
MUNICIPALITY N 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 REMEDIAL 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.
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