HomeMy WebLinkAboutBldtr-20-000751 . 11-12-14;11 :54AM; ;5083980836 # 1/ 2
: . TOWN OF YARMOUTH BUILDING DEPARTMENT Permit Number tT/2 20
:y£ 1146 Route 28,South Yarmouth,MA 02664 Date Issued
.(� ,�,��.: ) 508-398-2231 ext.1::611r Fax 508-398-0836
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Expiation Date
• $50.00
TRENCH PERMIT
Pursuant to G.L.c.82A§1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of ApplicantSC m 5j`�GKmG Phone Cap
� �n E�cc�*,r\C L C 5e-yid-55� 1-14-83�- 648a
Se ct e•CAL W Email Address:Speak. nexCc1\10.bn?c@most \•`-(Dm
City/rowa . A ZIP
CANNIlc.\-, Oat S
Name of EEreo•otor(if dEf erect from applicant) Phone Cell
Strem Address
S '`Ylt.
Email Address: I!
Cityll'own MA ZIP
None of Ownerts)of Property ?pi 444 eta
severe Addras3 361/tiRv L " Email Address:
Ckyfrown MA ZIP
Other Contact I Permit Fee Received No( Yes()
Description,location and purpose of proposed trench:
Please describe the exact location of the proposed trench and its purpose(include a description of what is(or is intended)to
be laid in proposed trench(ea;pipesknbk Hues etc..)Please use reverse aide if adt hotel space is needed.
3 sActIuwAi w -- S fC ec ,k_ RECEIVED
r______
AUG 0? 2J19
BUILDING DEPARTMENT
Insurance Certificate M: `/st cc_ 500 -- 500 8 75O a O 19
Name and Contact information of Insurer: -- ~
f;SSauGreca &rrptO XS \S Co,64-T1(1'Yd BVi)$&rrt rl () CY1A O1gO3
: Policy Expiration Data ntiatia.orl
Dig Safe it: ,01-L,321110 i
Same of Competent Persoe tax defined by 520('MR 7.02):
G.r(\ Spe.0 -'mQ.)n
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Masudswede Ileistbqg License F HE t 3 3 0GO
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Line.Grades D P Expiration Date: I 1 jay /aol q
BY SIGNING THIS FORM, THE APPLICANT, OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF THE WORE.WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLIUDING OSHA REGULATIONS.
G.I.. e. SIA, S20 CMR 7.00 d set,, 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 OR 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 WOIUL
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
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 PERMttr,nancnoris MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES TAKEN BY THE
MUMCWALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO
COMPLY THEREWTTB INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED NECESSARY BY THE MUNICIPALITY.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND 1NDEMNwY,AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS SEVERALLY
EMPLOYEES FROM
ANY AND ALL LIABILITY,CAUSES OR ACTION,COSTS,AND EXPENSES RESULTING
our
OP ANY INJURY, DEATH, LOB OR DAMAGE TO ANY PERSON OR FROM OR ARISINGCONDUCTED UNDER THIS PERMIT. STY DURING` THE WORK
APPUC GNATURE D
DATE ®/J��lr
CAVATOR SIGNATURE(IF DIFI•EREN'I')
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
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