HomeMy WebLinkAboutBLDTR-20-003272 ,�. g Ya , TOWN OF YARMOUTH
R4r0 BUILDING DEPARTMENT Permit NumberZv- im- 0/v 3Z7 -
al/ 1 y 1146 Route 28,South Yarmouth, MA 02664
.y.' 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
Expiration Date
$50.00
TRENCH PERMIT
Pursuant to G.L. c. 82A 11 and 520 CMR 7.00 et seq.(as amended)
THIS PERMQ MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
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Name stApplkant �',4Pc .c cn�rRa4c� 3, �CU Phone Cef
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Street Address — Y Z
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City/Town MA ZIP
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Name of Excavator of di[terent from applicant► Phone Cei
Street Address
City/Town MA I ZIP
Name*Mountie)of Property Phone Cer
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Street Address
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Cky/Town / MA I ZIP
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Other Contact I Permit Fee Remived No( I Yes( )
Description,loadoa and porpoise of proposed trench*
Please describe the wait location of the proposed trench sad its purpose(include a descripdsa of what is(or is intended)to
be laid in proposed trench les;pipes/cable Naes etc..)Please use reverse Ade E additional space Is needed.
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Yam sadContact Information of Insurer f r,
Polley Expiration Dote ( Z. - I -;-c.)
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Yam of Competent Person sae defined by 520 CM*7.02):
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Ucena Grades C't'E e2 A Expirstior Date:
BY SIGNING THIS FORM, THE APPLICANT,OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WTFH,OR,BEFORE COMMENCEMENT OF THE WORK,WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED.INCLUDING OSHA REGULATION
G.L. e. CA, 52i CMS 7.511 d se*, 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 COVERING SUCH WORE.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED SY THE
MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OW STATE LAW AND CONDITIONS of
THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES TAKEN SY THE
MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO
COMPLY 77IE*ZWTTH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED
NECESSARY BY THE MUNICIPALITY.
MR UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDEMNIFY,AND HOW HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM
ANY AND ALL LIABILITY,CAUSES OR ACTION,CO61S,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 � � �_o2O ,�
EXCAVATOR SIGNATU (IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
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