Loading...
HomeMy WebLinkAboutBldtr-20-000892 'YAR TOWN OF YARMOUTH jub�1Z -' '! ' -61 4o_ BUILDING DEPARTMENT Permit Number �( ,: e : y. 1146 Route 28,South Yarmouth, MA 02664 E" }ftw! r , 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued Expiration Date $50.00 TRENCH PERMIT Pursuant to G.L.c.82A 11 and 520 CMR 7.00 et seq.(as amended) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION New etApplicant ©r+h ws`T Co c_ -;o-, . Phone - Cell Se3o1 �L '5yS444-1,.,3° xcilvr+1-l;o.1 cnr P. 5"01?- 8% 7713 Street Addreta 3a SIACA 1 NIN LtJ e- O• 6OX a3S City/Town MA ZIP (D3) Name of Excavator(if different from applicant) -Phone Cell Street Address C City/Town MA I ZIP Nano of Ownerist of Property 5..e 1100 M 1 rimPhone j Cell ,Street Address �el1N S0 O�7 3 t7 3 a Em, 55-1 LA) City/Town MA ZIP \lier rill0 tkrk-- ct. OiContact I Permit Fee Received No Y ( } es( ) 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 rca;pipes/cable lines etc..)Please use,n verse side it additional space Is needed. De- fro14'c RECEIVED AUG 162019 BUILDING DEPARTMENT �I insunnee Certilkate 0: M � 9 a Li .�, — !1ae►>Iu and Cowart information of insurer: K.09 � '� ro f')4 Yam- 43 ti lv1 � ►3 9 S © b b e) ligation Dote: — I a — a o -C nrsSateN: a019 331 2 (9. / Neme of Competent Person um defined by 520 C'MR 1A32): o b -rU I 1 och Iof2 , Mouscfiueetts Hoisting License# f<pj 043 575 /5 I ' Limo Grades oZ k _Expiration Dater I' / / 1/ 6 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. STA, 52S CMR 7.00 at 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 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 ACT 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 WI 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 TEE PUBLIC WHERE TIM 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. APPLICANT IGNATU l DATE F /f0` 1q EXCAVATOR SIGNATURE lIF DIFFERENT) DATE OWNE S SIGNATURE I DIFFERENT) At ` e� f—/Li—/ 9 w_ - DATE: 2 of2