HomeMy WebLinkAboutTR--20-3061 OF YARMOUTH
.. TOWN Permit Number
/; ay'YAR BUILDING D�'pARTNIEI�1
�'' �U MA 02664Date Issued
.�'J 1146 Route 28,South Yarmouth, .
o, - ,� 508-398-2231 ext. 1261 Fax 508-398-0836 _
QV.wta $50.00
TRENCH PERMIT
nt to G.L.c.82A ill and 520 CMR 7.00 et seq.sas amended)
j�)<SUS D PRIOR TO CON
THIS PEAMU MUST SE FULLY COMPLETEIDERATION
Phone.
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of Applicant
Street Addrev" ✓Q R ,
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Name offrom applicant) 1��Cell ( I�
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Name of Ownerls)of property (� �, �'
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Street Address ` L J
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cuts
City(Toan MI L 6 , .
pern>u Fte �red No Yes
Other Contact of proposed trenchz (include a description d what is(or i,intended)to
Ueset't describe be the exact end perP°� trench and its purpose is needed.
lamina proposed side if additional space
b Please do rench leg; i cable tines etc..)Please use reverse
be raid in proposed. C'l ► t2.A r i) 7 2 J
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insurance Certificate Ili � --.-
Negate and Contact informa��Qtinnr insurer fSiL�f� '��
Po i~t.intionDate:
Dig Safe M: L 'r U Ll L 1
or � _" 520 C'tilA 7A2):
,yarns of Competent Person Ias defined by �� r' '��
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License Grade: )4k Expiration Date: "
BY SIGNING THIS FORM, THE APPLICANT,OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF THE WORK,WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,
G.L. a SZA, ne CMR 7.00 et eeq., 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 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 THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
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 HARMIPAS THE MUNICIPALITY AND ALL OF ITS AGENT'S 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 S
4-1J DATE i11d,g.1
EXCAVATOR SIGNATURE(IF DIFFERENT)
a'A
DATE \\`%--6t\C`
OWNER'S SIGNATURE(IF DIFFERENT)
ftrulitik Q DTL(rf,1'1/\,ty2. DATE: /// Vi 1
roe I.b aae—Dot net write hi tie
Nst . �poiltition Fee
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