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HomeMy WebLinkAboutBldtr-20-001441 ,a�•Y4.-.,,le TOWN OF \ : RN[Ot'TH Number � - 0 _ 63/yy/ .. .. ' E r o BUILDING DEPART1IENT Permit 0;It 1 )yE , 1146 Route 28. South Yarmouth. NIA 02664 , ' �08-398-223I ext. 261 Fax �18-398-O836. 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 Fit,S (bco/i/-r/s' Coii7 Phone CeU Street Address 3 Eh ii,r r, sie ,2�',/ S c t. 3 (dam 6013.7 Gttty/fl'own IZIP m yel 1 r► ri-t.7 sI me of Excavator(if different from applicant) Phone Cell Street Address City/Town MA ZIP I Name of Owner(s)of Property Phone Cell Street Address ')-- 7 3 ,- 060, L'n tw i t-- ii-e. City/Town MA I ZIP Scx<th biar cat ►a 1 cam' 75 Other Contact L 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(eg;pipes/cable lines etc..)Please use reverse side if additional space is needed. Nos ��r Y S, _ _ -�--- ir Cs VE (, t A S " / S IL • Insurance Certificate#: m WIC SM Sc)oU70G ) ib-/^ ______ Name and Contact Information of Insurer: 1 4 1 fil M LOk dy.I jh r1 e F c ' Policy F.xpiration Date: id-13 i 4.015 Dig Safe if: ao19 370 0611 Name of Competent Person(as defined by S20 CMR 7-02): 1 of 2 Massachusetts Ho License F I I 03-8"67 w License Grade: it e r (,v* S Expiration Date: I 9 I3o I d c9C:d 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. c. $L1, 520 CMR 7.01) 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 EY 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 DATE EXCAVATOR SIGNATURE(IF RENT) DATE © 'S SIGNAT/U (IF DIFFERENT) 4 )1-z_ / - . DATE: 6—Zc;(Zc/P.-- ( For t9e�/I'a oat--Reaiat or* MII rs = - t � A rer Onto • T i It f i AL • 2of2 Commonwealth of Massachusetts ti Division of ProttLesswnat ucensure Hoi +9 Eti er ji�ires_12/30/2020 HE-028673 LAURENCE F EL uS° `` Irr Ws, 8 NORTH ST 0263� DENNISPORT s_ .\ Commissioner • Hoisting Engines Restricted to: HE-2A-Excavators DIG SAFE Call Center:(888)344_7233 In case of accident call: 508)820-1444 For information about this license Call(617)727-3200 or visit www.mass.gov/dpt -^" 1 REID&LA-01 CLEDDUKE ACt7/eC, CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDmYY) `-� 12/06/2018 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 the 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 WitirCT Rogers&Gray Insurance Agency,Inc. Na,EA):(800)553-1801 I FAX )816-2156 434Rte 134 l lA(c.No):(877 South Dennis,MA 02660 mail©rogersgray.com INSURERS)AFFORDING COVERAGE NAIC# INSURER A:West American Insurance Company 44393 INSURED isuRERs:Arbella Protection Insurance Company,Inc. 41360 Reid&Laurence Ellis dba Ellis Brothers Construction INSURER C:A.I.M.Mutual Insurance Co. 33758 23 Enterprise Rd,P.O.Box 59 INSURER D: Yarmouthport,MA 02675 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE �"SUBR POUCY NUMBER POLICY EFF POUCY EXP LIMITS LTR INSD WVD (MMDD(YYYY) (MIWDD/YYYY1 A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR BKW(19)58371201 03/01/2018 03/01/2019 PRREMiEEs cEaEMoaxlEDnence) $ 100,000 MED EXP(Arty one person) $ 15,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEM.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JRQ; LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: Et S B AUTOMOBILE LIABILITY (EaCOMBINEDidentSINGLE LIMIT ANY AUTO 1020002607 06/09/2018 06/09/2019 BODILY INJURY(Per person) S 250,000 AOl1TOS ONLY X AUTOS BODILY INJURY(Per accident) $ 500,000 X AUTOS ONLY X AUTOS ONLDY warEacgrenemiAGE 100,000 S _ UMBRELLA UAB OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE AGGREGATE S DEO RETENTION$ C WORKERS COMPENSATION X PER ER AND EMPLOYERS LIABILITY WCC50050007062018A 12/03/2018 12/03/2019 100,000 ANY PROPRIETOR/PARTNERIEXECLMVE YIN E.L EACH ACCIDENT $ Q�F-IC�ER/M9M EXCLUDED? N N/A 1"""'Mor h^NH; E.L DISEASE-EA EMPLOYEE $ 100,000 I yes.desalbe rawer 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POUCY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101 AddWOnal Remarks Schedule,may be attached if more space Is required) Certificate holder is an additional insured under General Liability for on-going operations when required by Written contract or agreement CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTH�O^/RIZED/}REPRESENTATIVE �C JjWyll ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD