HomeMy WebLinkAboutBldtr-20-001811 TOWN OF YARMOUTH ILL -2r -( D/ - I
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c• BUILDING DEPARTMENT Permit Number
0
� !„ t' i H 1146 Route 28,South Yarmouth, MA 02664
'�'yl.,,,n i,. ,y 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
Expiration Date
$50.00
TRENCH PERMIT
Pursuant to G.L.c.82A 31 and 520 CMR 7.00 et seq.(as amended)
tins PERMIT MUST RE FULLY COMPIX ED PRIOR TO coNSininik on
Maass at Applksdsz tmkir, PhoneCen
Street Address 'Z3
City/townMA ZIP �_ ��
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Naar of Excavator(it different from applicant) Pitons Cell
Street Address
City/Fowls I MA ZIP
Naar of Owners of Property __�
P6orr' Cell
Street Address \ r , c`7--
Ckyfrowwn MA I ZIP
Other Contact I Permit Fee Received No( Yes(..,
Description,location and purpose of proposed trends
Please describe dre exact loam(,den proposed trench sad its purpose(Include a description at what is(or is intended)is
be Laid in proposed trench(es;pipeafeable lines etc.)Please/ewe reverse%ids it additional space is needed.
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Insurance Certificate tic L
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Yams sad Contact Intormatlnir of insurer 'O -- -.-
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Policyi_sQiratfaw Date: L( w�'' �3`/3
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Name of Competent Perna ins defined by 520(:1M11 7.02;:
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urea.Grades .-A - Expiration Date•. k`S l
BY SIGNING T1US FORM,THE APPLICANT,OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILWt WITHa,OR,BEFORE COMMENCEMENT OF THE WORE,WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED`INCLUDING OSHA REGULATIONS,
G.L. e. P2A, SIi. CM* T.M d seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND
REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ZEiUED VOIR
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 WORE ON THE PROPERTY OF THE OWNER, AND ALSO, FOR THE
DURATION OW COI TRVCITON, 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 APPLCANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REIM*U THE MUNICIPALITY I'OR ANT AND ALL COSTS AND EXPENSES INCURRED BY THE
MVIOCIPALUTY IN CONNECTION wnIH TAM TEHMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT LIMITED TO ENFORCING TES REQUIREMENTS OW STATE LAW AND CONDITIONS OW
THIS PERMIT,INiWECTIONS 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 EY 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 ARMING OUT
OP ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER 11119 PERMIT:
APPLICANT SIGNATURE
DATE /C/p2/1
EXCAVATOR SIGNATURE 11E DIFFERENT)
DATE
OWNER'S S TURL t IF DIFFERENT)
DATE: e2
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