HomeMy WebLinkAboutTR-20-1421 . 1-1t12-14;11 :54AM; IUVOJVovoOU +*
:, , ,.dry. 'OWN OF YA OUT Penanit Nurr{ lie- Q D fa i
,: BUILDING DEPARTME o
,....s\� 1146 Route 28,South Yarmouth,MA 02664
� Date Issued
.H - !.-_ .. 508-398-2231 exf.1?6i Fax 508-398-0836 i _
. Expiration Date
• $50.00
TRENCH PERMIT
Pursuant to G.L.c.82A 11 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Named S��n1 K r'Gnp Phoa Cei
Applicant
a.r'1 txCr 4\ny 1..1..C. -Lisa-55(zS -I1+ -83( 648a.
Street
n Jpe.0\k- VNI _ Email Address;SpCak.rrY�n�cic�o,�+n0�11c@hoi��4.i-err
City/roamti Ch a
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Name of Excavator(if different from app nst) Phone Call
Street Address
S Gmt Email Address: I
Crown MA ZIP
Nam of Owaesls)of Property Mae. Cell
.art Fcylivti
Street address
L.SMA E Email Address:
City/Town MA ZIP
Other Contact I Permit Fee Received Not ; Yes( )-
Dosaiption,loaded and purpose of proposed buck
Pease describe the exact location oldie proposal trench and its purpose(include a description of wbst is(or is intended)to
be laid in proposed treach(eg;pipadeabk lima etc..)Plena use serene tide if addend space Is needed.
i pg,1vi/V5- 'T� CIS CC& — ,5e 7'C r,nvs7ia.Lk.
1, , cEivp _-I
SAP 11701J 1' 7
IInsurancee : \RCS -SOo - 500Z75d— aor, A �� ,: .
J. a
I Nate and Contact Information of Insurer: _-
1 ASSac okke Err\Vk Ye -InS Co-5L‘-ch Yd PNic Bur i1nBkon MA 01%03
• Policy gyration Date: n 1 r:I.i p.C511,4
Dia Safe N: aOlq $7 / 1233
Nome of Competent Person t as defined by 5111 CUR 7.8.2):
Grp Spec X-rc\o.,'n
Iof2
S E_ 1330cc)
• License Grades 'R _g: ,Date: t \ Jc). l ao'9
BY SIGNING THIS FORM, THE APPLICANT,OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAPULIA*WITH,OR.BEFORE COMMENCEMENT OF THE WORK,WILL BECOME FAMILIAR
WITIL ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSTIA REGULATIONS,
G.L. e. f?A. 525 CMR TAM 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 WTTH 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 TEE OWNER, AND ALSO, FOR THE
DURATION OF CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND DHIP'ECT 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 THE PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING WI'NOT IAMPTED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF
THEE PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURED TAKEN BY THE
MUNICIPALITY TO PROTECT THE PUBLIC MIME THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO
COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED
NECESSARY BY THE MUNICIPALITY.
Till UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
14Ij M IPY,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 DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
Par tiberram —UP virillikt
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