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HomeMy WebLinkAboutBldtr-20-001082 ,. , o�'.YgR TOWN OF YARMOUTH � L }= pro BUILDING DEPARTMENT Permit Number p( ,A y 1146 Route 28,South Yarmouth,MA 02664 )„ .y�' 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 PEILMI's MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant Nor h E As7' now Con Sef+ c 0Y s :)cc.l rt+id,, Ca r p ©B -Z56-771 Street.+weirs,. 3eg-q�1- 4/1 69 SA ra Ai)4 LA) • d• 3°X o235-0 City/fowls MA ZIP ©D63/ Naas of Excavator Of different from applicant/ Phone Cei Street Address City/Town I MA I ZIP Now of Ownortal of Property Rf,55 Phone /Cer L Street Address 3 on� ponce d' . 3-6e- G5 - (p qo Cay/Pown 1 MA I ZIP 5� rmo I �3 G. Otbsr rantaet I Permit Fes Received No I ) Yes( I Description,load's and purpose of proposed trench: Please describe the exact tendon of the proposed trench and ib purpose(Jacinth a description of what is(or is intended)es be hid in proposed trench(has pipa/eable Bass etc..)Please use serene vide it additional space to needs. it 1-11 5+44/ ,Crii O i 1itk + Si C ©F r i AUG 27201 Insurance Certificate It e n 9 a 1—/ to L Name sad Contort informal m of Insurer: k�g n C ( 8 rAy 939 /4A — Fos*Expiration Dar. 2 n C!5 M °� (' �?O jD1SthR 3ai9 35-0 56 - . .'tams of Competent Person tax defined by SIO(:Vis 7.62): A- 1 of2 • M.srcheretfs Hoisting Liceue 10 (4 E U`j 3 51 . License Grades 2 14 _ Expiration Date: 9. l G/• 2 o Z D 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. 03A. 5211 CMR 7.08 d 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 Wrri THE CONDITIONS SET FORTH BELOW. THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE maim AND THE EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO, FOR TIE DURATION OF CONSTRUCTION, AUTHORS 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 TIE REQUIREMENTS Of STATE LAW AND CONDITIONS OF THIS PERMIT.INSmCTlONB MADE TO ASSURE COMPLIANCE THRREwnw,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 AGENT'S AND EMPLOYEES FROM ANY AND ALL LIABILITY,CAUSES OR ACTION,COSTS,AND EXPENSES RESULTING FROM OR ARISING OUT OF ANY INJURY, DEATH. LOBS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT. APPLICANT SIGNATURE DATE Y-a7` /et EXCAVATOR SIGNATURE(IF DIFFERENT) DATE OWNER'S SIGNATURE(IF DIFFERENT) 4� DATE: ^/ Pit Meow we—Doidewed 115 f � „ T , A. • I 1 1_ L1..^. ANL 2 of