HomeMy WebLinkAboutBldtr-20-000886 Mil
TOWN ® ' 4, b
(i.,:... , > o' BUILDING DEPARTMENT Permit Number
9, y: 1146 Route 28, South Yarmouth, MA 02664
�`� MAMC � _'��' ;08.-3t18-2231 ext. 261 Fax 508-398-0836
!irate Issued
-. ... Expiration Date
TRENCH PERMIT
Pursu2ait to GI,. e. 82A §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMEDY.F'I IID PRIOR TO CONSIDERATION
Name of Applicant ejortolatt 1 Phone Cell
Street A+'I Tess •9 C�$- P c�S- aeo
City/Town MA ZIP
Name of Excavator(if different from applicant) Phone Cell
Street Address
City/Town MA ' ZIP
Name of Owner(s)of Property p6 poh,c {,e���aa,n; Phone Cell
Address y 21/�\Oltt S%c-- O`2 y- 5JI — 96,80
City/Town MA ZIP
- C6t 1N o 5 C.0
Other Contact rmnit Fee Received Ne Yes( )
Description,location and purpose of proposed tree • 1 tarierw.eo R� _
Please describe the exact location of the proposed trench an ' pur-po^o(:sr-ludP 'on of w at is(or is inten ed)to
be laid in proposed trench(eg; pipes/cable lines etc..)Please use reverse side if additional space is nee e
`ittiv-- i+ie t�i*r 6colt-;cam 100-c 3,. J)o svo . .14cw�t . n G. 33:5 L x F'5b7R 0
Sk��.e. � �i`l ne/cer / / ir t/af'Miai).4q" Cevire_a-70
eiw`s( ic.,(9 6 t ,k co-lit-CA n.e_r_Es y 9' ,eyes-t
RECEIVED .
AUG 16 2019
Insurance Certificate#: BUILDING DEPART1IAENT
"O�o�� �gce� 10 By:
IQlaxand Co tact Information of Insurer:
S�. SW,e Q-o- 7o i30x3a$ Ou at 4., MN 5Sc. c,
Policy Expiration Date: 3 t1 I 0
Dig Safe#: 20/ 3 3 1 /f 9 9 949-o l kcl
Name of Competent�nt Per a(as defined by 520 CMR 7.(l2):
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M2S: _ousetts Hoisting License# /3 e/O9- /
/4//a1)
License Grade: ,PA. Expiration Date:
BY SIGNING THIS FORM, THE APPLICANT, OWNER, ANn> EXCAVATO t: ALL ACKNS-WLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH,OR, BEFORE COMMENCEMENT OF THE WORK, WELL I:.ECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,
G.L. c. S2A, 520 CMR 7.1i,I et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND
REGULATIONS AND THEY C•VENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUE I FOR
SUCH WORK WELL COMPLY THEREWITH IN ALL RESPECTS AND WTTBI THE CONDITIONS SET FORTH
BELOW.
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR. TO UNDERTAKE SUCII WORK ON- THE P (VERITY OF THE GWNE'!'• AND ALSO, FOr THE
DURATION OF CONS ERUCT!1 NT, AUTHORIZES PERSONS DULY APPOINTED Ic:Y THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE E 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 THF MUNICIPALITY FO ANY AND ALL COSTS AND EXPENSES INCURRED)BY THE
MUNICIPALITY IN CONNEC t ION WIT):` 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 E HEREWfl1I,AND MEASURES TAKEN BY THE
MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER 01' EXCAVATO' HAS FABLE" TO
COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED
NECESSARY Y THE MUNTICP ALITY.
THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDEMNIFY, AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENILS AND EMPLOYEES E!"OM
ANY AND ALL LIABILITY, CAUSES OR ACTION, Cart STS, AND EXPENSES RESULTING FROM 1 R ARISING OUT
OF ANY INJURY, HEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPE!•'TY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APPLICANT S A
�4(9 DATE
E VATOR SIGMA (I1r DIFFERENT)
!1� Ell. ill6110
'S SIGNATURE(IF !1Etfr EFFERENT)
tut DA E'E: 4I/ IO
-. • - . city/TO ate.—Do dot wa-IQ u 66u11 4to*: .• ••
PEII 'fl IN AUTEIIOI .
. A��m6iicauQe�¢n Hai
CONDITIONS.OP AOF APPROVAk.:' . ' _ .
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