HomeMy WebLinkAboutBldtr-20-001677 .og•AraR TOWN OF YARMOUTH . 344 7k- 4o- ot /G`J7
BUILDING DEPARTMENT Permit Numr
p 4,4 ' y 1146 Route 28,South Yarmouth, MA 02664
Y' �*• 4' 508-398-2231'ext, 261 Fax 508-398-0836 Date Issued
Expiration Date
2,6 20.0
SEP
r" TRENCH PERMIT
miP
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 77- V �T2,`v7' Phone Cell
Street Address � �� A1 I��Lc
y o [ � ��
City/Town MA ZIP
02 LA-1
Name of Excavator(if different from applicant) Phone Cell
Street Address _
SIW
City/Town MA ZIP
Namener(w f Property / i • Phone CellStreet A)I Ll V l
City/Town MA ZIP
Other Contact IPermit 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.
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Insurance Certificate#: S Zpirq
!yam!�and
.}��C/ WVC1i1774-(1C—e—
Policy ontact Information of Insure Expiration Date: {f) — l`12 J )
Dig Safe#a 0
Name of Competent Person as ddefncd by 520 C'MR 7.02):
1 of 2
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musachusetts Hoisting License 61+6 a_3 9oef)
• -19 2c2
License Grades A Expiration Date
•
BY SIGNING THIS FORM, THE APPLICANT,OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR W11TI,OR,BEFORE COMMENCEMENT OF THE WORK,WILL BECOME FAMILIAR
WITH.ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS.
G.L. c. SZA, SIB CMI 1.00 at 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 WORT[ 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, Amnon= PERSON 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 EXPEN884 INCURRED BY THE
MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED TENDER,
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 MUNRCIpALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM
ANY AND ALL LIABILITY,CAUSES OR ACTIONi,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. -
APPLriC lVA
DATE
91 K/11
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
R'S SIGN RE 4IF DIFFERENT)
DATE:
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