HomeMy WebLinkAboutBldtr-20-000885 S TOWN OF YARMOUTH �� 2 ��
o BUILDING DEPARTMENT
C Permit Number
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� r�t � 11J6 Route 28;'�outl) Yarmouth, CIA 1)2664
MA,TALM ,L- 508-398-2231 ext. 12611+ax 508-398-0836 Date Issued
Expiration Date
$50.00 .:
TRENCH PERMIT
Pursuant to G.L. c.82A §1 and 520 CMR 7.00 et seq.(as amended)
rais PERMIT MUST BE•FULLY COMPLETED PRIOR TO CONSIDERATTON
Nsats et Applic
antate aCa Vai l D Cell
Street Address I ki. 7 abeE2
C tyRown MA ZIP
errs-LClr�I
Name of Excavator tit different frogs applicant) Phone Cell
Street Address
City/Town MA ZIP
Name of Ownerts)of Property 60rtz.. • e Phone Cell
Street Address 2 Iq edef e-T zCitylT MA IIII•
Ot Contact I Permit Fee;Received Nut ) Yes
Description,location and purpose of proposed trench:
Please describe the exact location of the proposed trench and its purpose(Include a description of what is for is intended)to
be laid in proposed trench lea;pipes/+eable lines etc..)Please use reverse wide if additio
cceet ` ECEIVED
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AUG 16 2019
Y:
Insurance C'ertiikate if: 5 pp OP000O5 II 5
Vs a Contort Information cat/murex,
Or - ev(--,-, 114,5 sc)k-eee -5:5)(c----d
Pulley Espiratlon Dates i
' Dig Safe N I 3Q
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Name " nt Person I as defined by C'Wit 7;0):
_.._...&lar
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A k
Museefiusetts Hoisting License I f o- i.t g t7O
• License Grades 2 A
Expiration Date: 2,1(7(2.v
BY SIGNING 111E FORM,THE APPLICANT,OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF THE WORK,WILL BECOME FAMILIAR
WFfiL ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS.
G.L. e. EA, 52$ CMR 7.$ it 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
EXCAVATORDU U
RATION OF CONSTRUCTION. Amman PERSONS DULY APPOINTED BY T
HE AND ALSO, FOR THE
MUNIaPALITY 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 THEREWIIII,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,
INDEMNHFY, AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM
ANY AND ALL LIABILTIT,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.
APP T SIGNATURE
-�� `� 9( 66., DATE -lel
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
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