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HomeMy WebLinkAboutbldtr-20-000848 i' .o , � TOWN OF YARMOUTH (�c6172_ —�c.i, �-- z- .4o\ BUILDING DEPARTMENT ; Permit Number ,. Z C , 1146 Route 28,South Yarmouth,MA 02664 ; H „--(„cszzazossE�4J 508-398-2231 ext. 1261 Fax 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) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant( flictprfses Phone -ol 14-5 5ell Street Address 15 Q mom S w r_ Eru ail Address: ��'AT(r tabWa#,I` , Irn City/town MA ZIP & .unnis 62-kouo Name of Excavator(if different from applicant) Phone Cell Street Address Email Address: - - City/Town MA ZIP Name of Owner(s)of Propert) btu bcCIr CILS Phone Cell Street Address I R Y eb t Email Address:UWiTi, .ueernQ.1 I'1 CO City/Town MA ZIP t (/ (.Blau-rnouy OA 1o' 3 Other Contact 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(eg;pipes/cable lines etc..)Please use reverse side if additional space is needed. RECEIVED NJ-3 S- 19721t . AUG 14 2O19 SUfL• R n Insurance Certificate)!: , Name and Contact Information of Insurer: i� Policy Expiration Date: I Dig Safe K: Am &)9io 5059 1 Name of Competent Person!as defined by 520 CMR 7.02): l of Name of Competent Person(as defined by 520 CMR 7.02): re,gorcl Morn i Massachusetts Hoisting License# O1 144 I / License Grade: Expiration Date: (p• 112.0 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. 82A, 520 CMR 7.00 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 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 INSPECT THE 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 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 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. APPLICANT SIGNATURE DATE t •114' 11 EXCAVATOR SIGNATURE(IF DIFFERENT)DATE S .14. Q t OWNER'S SIGNATURE(IF DIFFERENT) rr'' DATE: b.I`1' 19 e z,.g re aye _,.......1 GFMEN-1 OP ID:KT '4 — CERTIFICATE OF LIABILITY INSURANCE DATE(MMIOD„-YYY) 08/14/2019 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(ies)must 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 such endorsement(s). PRODUCER CONTACTNAME: Eastern States Insurance PHONE 79000 642 781- - FAX Agency,Inc. (Alc.No.Ext): (A/c,No): 81-647-3670 50 Prospect Street E-MAIL tificatere uest esia.com Waltham,MA 02453 ADDRESS:cer q INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Ohio Security Insurance Co 24082 INSURED GFM Enterprises Inc. INSURER B:Acadia Insurance Company 31325 P.O.Box 1439 S Dennis,MA 02660 INSURER C: INSURER D INSURER E: INSURER F c 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 CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR BKS58044964 06/15/2019 06/15/2020 pREMISES Ea occur ence) $ 300,000 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY (Ea BIKED SINGLE LIMIT $ 1,000,000 A ANY AUTO BAS 58044964 06/15/2019 06/15/2020 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS AUTOS (Per accident) $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE USO 58044964 06/15/2019 06/15/2020 AGGREGATE $ 5,000,000 DED X RETENTION$ 10000 $ WORKERS COMPENSATION X PERTUTE OTH- AND EMPLOYERS'LIABILITY STA ER A ANY PROPRIETOR/PARTNER/EXECUTIVE YIN XWO58044964 06/5/2019 06/15/2020 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N N/.A 500,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B Equipment Floater CIM5308293 06/15/2019 06/08/2020 Own/Leas 1,690,414 Rented 25,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION YARMOMA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD