HomeMy WebLinkAboutBldtr-20-001912 OF YARMOUTH 4i.brIZ Z(�-'lGi IZTOWI'`I permit Nuer
a� BUILDING DE'PARTME
''r i$V MA 02664Date Issued
.�, �� c 1146 Route 28,South Yarmouth, .
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x) 508-398-2231 ext. 1261 Fax 508-398-0836
MATTA M ,,i ,iC•
441egilo`��
$50.00
TRENCH PERMIT
ended)
cant to G.L.c. 82A §1 and 520 CMR 7.00 et seq.(as end
p11TS I)PRIOR TO CON
THIS PERMIT MUST BE FULLY COMPLETEERAON
Mont CellNau+tof Applicant they�' �, Co 5A-143a-0S30
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Name ofU7vator(idiners;%[role appStreet ae" . imiiiiiiiiillilik
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i �� (� 1/1 �� Permit Fee Received No Yes
Other Contact �proposed treaehz (include■description of what is(or is intended)to
Description,
location purpose and its purpose is needed.
locatio location of the proposed trench •Jde if additional spate
b Please describe the exact i oe /cable lines etc..)Please use revue 4 ,,i�f��pp C
be laid in proposed c trench leg; `\. 1- 2 A r of V1(J�try 1 � l 1 e 31L1���
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insurance Certificate lit C 0 I ® / {
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Name and Contact information of insurer �;
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License Grades awl 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
WTPH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS.
G.L. e. SL , 571 CMR 7.M 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, AUTUORITFS 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.
APPLICANTS TURF
DATE 1O/ /)
EXCAVATOR SIGNATURE(IF DIFFERENT) i c�
C\4%. DATE Ali\k
OWNER'S SIGNATU (IF DIFFERENT)
DATE: /0 .v i
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