HomeMy WebLinkAboutTR-20-1527 ;og'Alt TOWN OF YARMOUTH b(,{ 2,2D-IEdi
. .` 40. BUILDING DEPARTMENT Permit Number
p •�,'' y: 1146 Route 28, South Yarmouth. MA 02664
?�� ..5 ,�4. 508-398-2231 ext. 261 Fax 508-398-0836 Date Issued
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 COMPLETED PRIOR TO CONSIDERATION
Name of Applicant 1:7kryl c(� 1 tK> i�J/�.N`]( f z Phone Cell
St 50?1
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bOX 775 _
CrownMA ZIP/ r f
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Name of Excavator(if different from applicant) Phone Cell
Street Address e A
Cityfrown MA ZIP
Name of Owner(s)of Property /� Li r�J Phone Cell
Street Address l'
t C-OU 0 I el.,0 1)a t v c,
yrruwn MA ZIP
b �1?�#O 6 2 Q(p4
Other Costa I Permit Fee Received No( ) Yes( )
Description,I Lion 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 reverse side if additional space is ed.
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RECEIVED
Inrcc5 C rtif (3----1- SEQ 18 2019
Na, and ntact Information ofInsu r: _ _--_..j
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� BUILDING DEPARTMENT
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olky Expo"rattonrn�'at'e: ,��j /
Dig Safe#:
(6)113t1 I 10 i 4
Name of Com rent Person(as deli by 3Z0 CMR 7.02):
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MaimInfanta Hoisting License 0.5(:)(23
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License Grades 9 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 REGULATION
G.L. e. 12A, 52B CMR 7.95 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 APPOINT BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE
CONDITIONS ATTACHED HERETO AND TILE LAWS AND REGULATIONS COVERING SUCH WORK
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
M��ALTTY IN CONNECTION WITH THIS PERMIT AND THE WORKCSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND ONDUCTED ED BYCURRED THE
INCLUDING BUT NOT LIMITED TO ENFORCING THE OF SLATY LAW AND 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
OP ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APPLICANTS C 4ATURE
fix.(ST4a
DATE
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
N 'S SIGNATURE(IF DIFFERENT)
APPROVED B Far Mama sat-Dti alit arils it tillDor
Pee
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