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HomeMy WebLinkAboutTR-20-1031 .__..;0'1, 1" 44 4. TOWN OF y'ARMOUTH &CJTT 2-,o —10 3 {+ o BUILDING DEPARTMENT Permit Number p "-e+i'' y 1146 Route 28,South Yarmouth, MA 02664 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 ApplicaVv M Cti ;..� ,�r Phone Cell Street Addy() fox 775 38 S ,3 City/Town MA ZIP E fVLS 02_604j Name of Excavator(if different from applicant) Phone Cell Street Address 5 -7')/7E City/Town MA ZIP Nail fvngT , /) r 1`i' 1 n " Phone Cell Street AddU// City/ wn MA ZIP EN1til S Ce �-/ •71 g--- o Other Contact O� n� I Permit Fee Received No( ) Yes( ) Description,location and purpose o pro trench: Please describe the exact location of the p posed 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 additional space is needed. 1_Ti45h1filadzf'l v (,UCH `,c-0/14 toA40.0 Po-rt RECEIVED I e Certificate 0 7`'� AUG z(� 201R . 5' �� sSUILU(NGDEPARTMENT Name and Contact Information of Insurer: By _^ Policy Expiration Date:Dig Safe 0: catOlCt 3,90 /2<<L Name of Competent Person(as defined by WbuJtt( 5 ): 1 of 2 • Massachusetts Hoisting License B /re (15 We Lkeme Grades az p Expiration Date T'�9'go 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. e. S2A. 32! CMR 7.85 et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BYLAWS AND MUTATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER TUE PERMIT ISSUED FOR SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WIT© 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, Avg PERSONS DULY APPOINTED BY THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONITOR AND INSECT THE WORK FOR CONFORMITY WITH THE CONDITION ATTACHED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH WORK. THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO REIMBURSE TEE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE MUNICIPALITY IN CONNECITON WITH THIS PERMIT AND THE WORE CONDUCTED THEREUNDER, INCLUDING BUT NOT LIMITED TO ENFORCING THE'REQUIREMENTS Of SLATE LAW AND CONDITIONS OF THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH.AND MEASURER 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 EMPLOYERS 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 ATURE 0°)1:.(3Ca,‘,19 DATE EXCAVATOR SIGNATURE(IF DIFFERENT) DATE OW R'' SIGN RE(IF DIFFERENT) DAIS: ' ,1j �BK For Ciirlt r-Obmtsiri1i*wag • 2of2