HomeMy WebLinkAboutBldtr-20-001390 41:-
t VtiVLN OF �r ARMOUTH 4).
A BUILDING DEPARTMENT ` P,BC,�772r 2v —l3 c10
• n Ni 1146 Route 28, South Yarmouth, MA 02664
ermit Number
1 ext.1261 Fax 508-398-0836 Date Issued
•
' Expiration Date
$50.00
' 'Pursuant to G.L. c: 82�1, �K1E�N�o�.RMLT
. . • CMR 7.00 et se9•(Se amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
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Name of E valor( ' 0�-C 5 1
� ����armpit applicant) Phone
Street Add dad;(,)l Q.-�l, •Cell
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Name of Owe OAli 5
n )of Prope*,
Street Address
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Other Contact
Descriptions location and purpose of proposed trench:Permit Fee Received No Yes
describe the exact bcatioet at the
Pe laid r the ere ce l that Pi of the
t proposed trench p�,an its purpose(include a desert
Re •erse aide It a pin of what de is(or 1a intended)to
bdtiilional she Is needed.
A. , ( 6 1
i
lasunmce CettiP !
Name a WI Pr S'C Y`to p
and Contact Information or Insurer:
. Pal Ex.'raft -�... ,�v "�7! i..`� `I
Die Sage II: 'on Date:. r'�l ., r
ompetent Person t • ned by 52p OM Th2):
a / '1.,.1 ' .41 / 1
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Masssdiusetts Hoisting License 0 H Eo f3e5 c 1 I f 49-' ^'�
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License Grade 44 E, ..,?.I 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, EGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,
L. c. SU, S20 MVR7.09 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 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
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 SIGNATURE
/ 4V-# .—
DATE
EXCA ATOR SIGN RE(IF DIFFERENT)
OWR'S SIGNATURE, (IF DIFFERENT)
et4--",tP DATE: q'3 "(•
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• For µlop it R--
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