HomeMy WebLinkAboutBldtr-20-001771 TOWN OF YARMOUTH
' o ';VRc BUILDING DEPARTMENT Permit Ntm`b�c + 0 (l�J 77✓
p(- i.1g y 1146 Route 28,South Yarmouth,MA 02664
~ , 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
Expiration Date
$50.00
TRENCH PERMIT
Pursuant to C.L. c. 82A 11 and 520 CMR 7.00 et seq.(as amended)
THIS PERMI?MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Appikant 0 , a, PTO ` i y. i Phone 5048 Cell
Street Address 114-c �,• a-� 9
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Cityllown MA ZIP
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Naor(if different from applicant) Phone
Cell
Street Address
Citylrown J MA I ZIP
Naar of Ownertsi of Property , /etcrcR e
Street Address W 6 g
, 36a
Chylrown MA ZIP
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Contact [Permit Fee Received No( Yes( )
Description.location and purpose of proposed trench:
Place 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(es;pipes/cable Noes etc..)Please use reserat:dde if addHbnai space Is needed.
9trWr1/4L6 -ZI-Ayl-TRAA/V --)U1/4/eZrZeksz. .-R.QAA,
OCT 01 2011
Insurance Certificatett: 5:7 AS"
MAAR P 'o09
Name sad Contact Information of Insurer
Po Esping Date: 5`t -
Dig Safe IP: DO 1 g 36n 1 " 51-1
'came of Competent Person l as►e ined by 520(MMR 7.02,:
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License Grade:
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 WORE PROPOSED,INCLUDING OSHA REGULATIONNS,
G.L- e. ILA, 520 CMR 7.0N et .e4, AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND
REGLT.ATIONS 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, Aim 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 THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF
THE 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
YY\ . D 1 DATE (0 1 1 \ -I
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
m O C7_CLLI.: .1/�^�� DATE: LO L t1 t
Fir 'b"+,rior me—Oti•y M*if Noctiie
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