The URL can be used to link to this page

Home My WebLink AboutBldtr-20-001536 --- TOWN OF YARMOUTH ',�="''YAR / t-Jb 7i2 -do -0453c i,� _46, `�o,, BUILDING DEPARTMENT Permit Num er o _ .0'-y� y ; 1146 Route 28,South Yarmouth,NIA 02664 ;Y „,,r•,,.„ , x, 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 iZt —IC v'3 Phone C, ,�1 ,t 7 CeU Street Addrecsi 31 v�d,�' A• ' 9,� t'"v _! ;/� ,�t, �� ,"�,,� ✓ v '`�v Email Address: 1 t � ,, 1 p�( (fl lk W'J>U✓�•1 City/Town �� MA ZIP 1. liff.Aftlt Name ✓oo Excavator(if different from applicant) Phone 70 5CCellStr �C rests at I f�sl - r 70 PQ - NY,) 1 C) Email Address: CityTfown MA ZIP • ItuilC . pu Name of Owneris)of Property Dam go t„n Phone CeU Street Address Y�-�'/l�+l 1! ^ _n s 7--M i 5 C� E _�Elmaill Address: City/Town MA ZIP kAlkli t\C"-S D1 14 -1 Other Contact r 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(es;pipes/cable lines etc..)Please use reverse side if additional space is needed. AO L 3 -7 PAwsS r(P 4- tWil . Insurance Certificate 0: 00,0 e jibe --7 9 o r„ /��i c /J Name and Contact Information of Insurer: I �,j1�(�9c(/,/ . a 1 Cib Policy Expiration Date: I Dig Safe I: ;()\c‘ c6b2)31dit(^ _____ i Name of Competent Person 1 ardefined by 520 CMR 7.02): _c-► 0 ' ,Name of Competent Person(as defined by 520 CMR 7.02): Massachusetts Hoisting License# Jie -()L )5 I License Grade: Expiration Date: it 1 5; ar() ; BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF THE WORK,WII,i.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 SI l .e. DATE e / qi fi EXCAVAT SIGNAT (IF DIFFERENT) DATE • OWNER'S S NATURE (IF DIFFERENT) DATE: 7-/S-? '°max". �� -ro-,, ' ,rt� 3 -s. - -�'". t e -"t bra_ .x' "-� X� s . 4W _� .� ,� >` - ,.,:�4--_- -+ems a, AC Ro CERTIFICATE OF LIABILITY INSURANCE DAIS:(MMlUD/YYYY) 09/06/2019 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of tho 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 CONTACTE Paula GilleSple NAM Snow and 1hurnson Insurance Agency. Inc PHONE 1 (50ti)43 -0130 .__T FAX ,,14 Maul Street IA/C No,Erstl (AIL No) 15on1 aso-t35o E-MAIL... ADDRESS: bllldsplegSnow I homson corn INSURER S AFFORDING COVERAGE __.. NAIC q E harmer]E Orl MA 02646 INSURER A: FAI Associated Employers Insurance Company INSURED _._ INSURER B: -- - Patriot(iuilders Inc INSURERC: _..-..__.. 53(Route 2b 2nd floor INSURER I): __. . _. _.... INSURER E. I arWlc.1 Port MA 0?646-1 tl94 INSURER E. COVERAGES CERTIFICATE NUMBER: kiwi'of Yarmouth REVISION NUMBER: 1HIS IS 10 CERTIFY THAT IIIE POLICIES Of-INSURANCE-LISTED Litt OW HAVE ELLLN ISSUED 10 IHE INSURED NAMEUABOVE FOR THE POI ICY PE-RIOU INDICATED NOT WITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CI RTIFICAEF MAY IiF ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DEi SCRIBE_U HEREIN IS SUBJECT TO Al) THE-TERMS. E XCt USIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS _ . INSR __ _._ - -- -ADDLSl1HR ___-- _ ---- -. UN TYPE OF INSURANCE INSD,WVD POLICY NUMBER (MMIDU YYYY► (MM UD YYYV) -_ LIMITS COMMERCIAL GENERAL LIABILITY - ----- -- - - EACH CH OLc u $RRENCE S DAMAGE'TO RENTED — AIMS MAUL. 1 I UCCuR PHI MIS(S iE GI fA-uianvel --- _. __-- _....._-... --- MI-NEAP(Any vile persol) S _ __ PERSONAL d Al V INJURY S UI NI_AUC/YLCi%UEI IMILAPPLIES PE ft CENTRAL AOUREGALF ;' I'RU -- PI)l ICY [ Jf c I LJUL PR(ll ltxa:; COMP/OP I i ._- COHBINFGING SE E I.IMi1 - $- - .AUTOMOBILE UABILI1Y . - -- (Ea aefif-Ifm11 ANY AUTO _ _ ESOIThY INJURY lPermelSwq Il BANE.U SLiiI-I/UI I I/ AU I i i�ONLY hUlO nl)I/ILY INJURY(Pe(acc 1-NI 5 1+W WO l? _ NON OMEE 11 PROPERT'r Di-Jvtr,%r3F-- - --- - Atli.ESi1NIY , A UO:5Urlli !He(4‘.adni1t UMBRELLA UAO UI C:�R EACI t UCCURRENf.E EXCESS LIAR 1 -InIM`MADE- i;r(:RE ;ATE $ .. _. i LI I, 1 1Rt It NI WORKERS COMPENSATION -----_--- .-- - -_- _. AND EMPLOYERS'LIABILITY Y/N 1�T 11E I _1 Pt A UflY Hit f It,Lkl/M[IMIiE�ER ExCI LIJE:INT IF,KECh i fVE N NIA Wl(,F005UO19962019A / c / / _ CCILIE N I ` 500 0UU 03/28/2019 03/28/2020 .r t LNLH (Mandatory In NH) _.__.1 — - .--. Ir vos deq:.IILO.u:klel F:E DI:,'E.HSE EA EMPLOYEE S bUU UUO II SCkm'UUW VE L)PF R.,I IONJ U:Ivx k t !A�[.SE t r�,ICY LIMIT _- _._. . UU UUU I DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES IACORD 101,Additional Remarks Schedule,may be attached it more space is required) - - - - - CERTIFICATE HOLDER CANCELLATION 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 26 ww A AUITIORI/ED REPRESEN MAUVE I" r , S Yannuutl, MA 02664 P.401:4' to 7 �.�L7'ti� 1 W . 5d'1\ i)1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD