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Home My WebLink AboutBLDTR-19-004140 y I k41•YaR TOWN OF YARMIOI'TH to BUILDING DEPARTNIENT Permit Number . 01 Op'.e�.' two Route 28, South Yarmouth, NIA 02664 4� - .7,42' 508-378-2231 est. 261 Fax 5(18-398-0836 Date Issued Expiration Date 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 /jam) Q 6 n7. rs Cphy) Phone Cell gm Street Addressg2 oitoravir2e /u/ sem' 3 Ga- Ga- ) Cityfrown MAll ZIP bion,--rii«.- (?2-G Name of Excavator(if different from applicant) Phone Cell Street Address City/ own MA 1 ZIP Name of Owners)of Property //, N'-)R 4ti4 Phone Cell Street Address tis 40o- o -1-1/1 IG Ls Pr Sds 776 9-&?c City/Town MA I ZIP - 1 a73 Other Contad 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 leg;pipes/cabk lines etc..)Please use reverse side if additional space is needed. i)el Sd 411 SepWC • i JAN 15 2019 IosunnceCerlificale0: 0I L._r-u�Nco�r�erM�trlr WGG goo S0oo 900a gre9 i Name and Contact Information of Insurer. I ,r," A i )1 rel 4 I fhS s "--1"44- -- Policy Expintion Date: - i3 3 119 Dig Safe II: X0/9 G30 ,2ll0 Name of Competent Person las refined by 520 CSIR 7.02): ' Lys -ff6h 1 oft 7 Mswuhreeta Maims License: ff L- 0 oZ e 6 73 H 4'a/3o 1a° a° License Grade: A )5Ang ktExpiration 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, CL e, 82A, 520 CMR 7A0 et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FDR SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WTCI TILE 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 THE 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 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 DIE 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, INDEMMFY,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. APPLI - � ? CQJI�RE DATE V '1- � ` EXCAVATOR SIGNATURE( IFFERENT) DATE • OWNER'S SIGNATURE(IF DIFFERENT) Iii DATE: /e id(1//� . Fut CMtiNTwan—DOtinl*rise Sothis seetier PIit.MII A PPROH f:D Bl'..': sem; ;_Applic•ation Fn PERMITTING AVITIOR n Date CONDITIONS OF APPROVAL • . • • 2of2 • REID&LA-01 CLEDDUKE .4cORo• CERTIFICATE OF LIABILITY INSURANCE °"'2(MAID°r"" ' L.� 12/06/2018 This CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER This CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of suc�hpeeTnpdCoTrsement(s). PRODUCER NAIrE• Roger"8. Insurance Agency,Inc. Pa2HONN, (800)553-1801 Fax 44344 L , me). (AIC,so(877)8162156 South Dennis,MA 02660 y s;mailgrogersgray.com BISURER(SI AFFORDING COVERAGE NAIL IN ' A:West American Insurance Company 44393 INSURED IN , e:Arbella Protection Insurance Company,Inc. 41360 • Reid&Laurence Ellis dba Ellis Brothers Construction INSURER c:A.I.M.Mutual Insurance Co. 33758 23 Enterprise Rd,P.O.Box 59 INSURER D: Yarmouthport,MA 02675 INS E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDmONS OF SUCH POLICIES.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLPOLICY SUBR EFF POLICY EXP LTR TYPE OF INSURANCE NH Tyyp POLICY NUMBER IMMIDD/YYYY1 (MAVDDIYYYY1 LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE _ $ 1,000,000 CLAIMS-MADE nOCCUR BKW(19)58371201 03101/2018 03/01/2019 P�REm65EESO/EaocamDanrel S 100,000 MED EXP(Any one person) $ 15,000 _ PERSONAL&ADV INJURY S 1,000,000 GENLAGGREGATE UNIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 GE��4POLICY❑ga D LOC • PRODUCTS-COMP/OP AGO E 2,000,000 OTHER S B AUTOMOBILE UAUTY COM ENDISINGLE UNIT BIS _ ANY AUTO _ 1020002607 06/09/2018 06/09/2019 BODILY INJURY(Pepernm) $ 250,000 _ AUTOS ONLY X NNp ryOE.pSyULED BODILY INJURY(Pr acceleml $ 600,000 X HIRED ONLY X AUTOSWJLY PR�ERY(DAAIAGE S 100,000 _ UMBRELLA UAB _ OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE AGGREGATE S DED RETENTIONS S C MAIDKERSCERS'L X STATUTE ER"- ANYPROPRIETORPARTNER/F,XECUnVE Y/N WCC50050007062018A 12/0312018 12/03/2019 E.L.EACH ACCIDENT S 100.000 QFFICER/MEMpEREXCLUDEDT n NIA 100.000 IAI+DeMory In NN1 E.L DISEASE-EA EMPLOYEE $ Orax y0S,RIPTIO0e9a1beNbelow 11°er 500,000 DESCOF OPERATIONS EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101 AddNonal Remarks Schedule.troy1 be attached more space h�wraa�.._-----_- -. Certificate holder Is an additional Insured under General liability for on-going operations when required by written contract or agreement-----------_.___ CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Route THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Tow Tow ofYar28. ACCORDANCE WITH THE POUCY PROVISIONS. 1146South Yarmouth,MA 02664 AUTHORED REPRESENTATIVE ACORD 25(2016/03) ®1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD .r Commonwealth of Massachusetts• • tLV Divisionof Professional licensure HV Pbgir 2� y ars:H2-028673 T w j) .o W1 ),4 n i 1 OW r 8 NORTH 87 i „ w �.. .•it'd DENNISpORT�jjq_02636;,.i.�,S• +fit Commissioner a i - , Hoisting Engineer Restiwtedto: HE-2A•Excavators r DIG SAFE Call Center:(888)344-7233 In case of accident call: 608)820-1444 • For information about this license GS(617)727-3200 or visit wwwmass•govldpl