HomeMy WebLinkAbouttr-20-1837 _
/ ';, ) d BUfDNG DEPARTMENNT Permit T` u3rAfgr
( 1146 Route 28, South Yarmouth, MA 02664
°i -= �/y Date Issued
., �.��=� =s Z 50S-398-2231 ext. 261 Fax 508-398-0836
Expiration Date
TRENCH PERMIT
Pursuant to G.L. c. 82A. §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPY FTED PRIOR TO CONSIDERATION
Name of Applicant a Cnst.r �oc. Phone Cell
r�o,o
' Sod- 0003,T 9
Street Address
'P.o.ax 'ivy
City/Town MA ZIP
Met/16kJ KU*. 0 trS
Name of Excavator(if different from applicant) Phone Cell
Street Address
City/Town MA ZIP
Name of Owner(s)of Property J ram,vj k k4rjynizig..) Phone Cell
Street Address /y 3 14, S{-- (,e J7-&l'//�- 7?9g
City/Town - ZIP
PA.C.AR ALAAAx 12;31 O. 9O Co
Other Contact Permit Fee Received No( ) Yes( )
Description,location and purpose of proposed trench: 3 Q Eri c_Kson La41 - `.Se j)4-i C- -S-0-0-iotn
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 ad.'aortal space is needed.
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Insurance Certificate#: Lo W33 OCT 0 1019
(fig Ce`7-3(e
Name and Contact Information of Insurer: C 6*` L00-7(j
4.8e2evete<0.9 gS8- 333 9.9'y9
Policy Expiration Date: 3 ') f J.UD-l-
Dig Safe#: & / 9 c/o O ?l l(//
Name of Competent Person(as defined by 520 CMR 7M2):
1,
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Mas: _,losetts Hoisting License# i 13a 5
I6-II it A.0,U
License Grade: 5 A- Expiration Date:
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, 52® CMR 7.1„1 et seal., 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 WELL COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SEI FORTH
BELOW.
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WORK ON- THE PROPERTY OF PrE OWNER, AND ALSO, FOR THE
DURATION OF CONS D XUCTION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT TIE 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 I'HE
MUNICIPALITY IN CONNECt KIN 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 MUNIC l'ALITY.
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, C•STS, AND EXPENSES RESULTING FROM OR ARISING OUT
OF ANY INJURY, ',1 EATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WO:'K
CONDUCTED UNDER THIS PERMIT.
APPLICANT-SIG ITRE
..../..7._... DATE ( 6/)/9
E: TOR SIGNATURE(I F DIF
FERENT)
DATE ie44...�Ic/
OWNER'S SIGNATURE(DID'pj RENT)
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DA l'h: / 0 \ 1 d•O 11
- . Ft*EaiviT0 a ue.—Dq,tint write.id this eecttitis a;,.. . .-
PERRMIIir APPROVED.BY ;`'; :Airnaki 6 F
PE:RPe'IMIN AUTI ORITi ' : ` . Dhmde'"_. .• -_ .,.-•.:.. -
CONDITIONS O€APPROVAL:, , -•
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