Loading...
HomeMy WebLinkAboutBldtr-20-003153 ' YARMOUTH �2-7,0---3 - TOWN OFPermit Number'` co Y BUILDING DEPARTMENT '�' 1146 MA 02664 Date Issued �' 5 Route 28,2South Fax 508-398-0836 . 0 508-398-2231 ext. 1261t.. . k�,.�lor.,E $50.00 TRENCH PERMIT amended) cant to G.L.c.82A 11 and 520 CMR 7.00 et se.(a nd nd PUTS p PRIOR TO CO THIS PERMIT MUST BE FULLY COMPLETE ON 11 .�,�7 (�� Cell Applicant . � •-C,�_� CO ___________________ n`� C� 8 Street Addr� ('Az A..c • S-Zr `- CityRown ` VIIZIP �' � 1'\ . 0 CO` Naat of Exca tr li[different[rom epplicaMl Phone CCellVyI1- o Street Add 9n L1 "O 2/Q_ 9 1 CA 1f1A /J t, 1,f--C.> Ly/rown MA ZIP � ��, © Cell S . k Phone ��— �0-3— jca Naone of Owned')of Property D` �J�C7 Street Address 1 �.� `�Y mil, �� �,P � � MAi City own MIIIIIIIIIIIIIIIIIIIIII ,eA giv\c ot ri\9 Permit Fee Received No Yes ��Contact of Proposed tnnchs (include a description d what is(or Is intended)to Description,adescribe be he exact and purpose the proposed trench and its purpose(include i[de•descr space Is needed. _ • b Meese dnxri p s d ench(e*;pipes/cable lines etc..)Please use reverse be laid In proposed k (�o A r ©6 k eN�� t �-4 l C CI, CIL 1S1 �-Ce-cv^, 1).JS Crc l\ co'1 c:2I0 v. Insurance Certilicete itt C G F.\ i 3 0 19 , tion of insurer. Vent end Contact i`n[nrma _-- 1-\\I 1::IJ �(1Jet•<lb�C. I • Poi Ex•irstion Elate: MO Dig Sate ilt a„O q— Cl6" 0S0 Slone of Competent Person las defined by 520 C}1a 1.011: I 611t4 L4r' ' 1 of 2 • Si9laf) LIcense Grsdes CT`T`r 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, C.L c. 52A, 5211 CMR 7.00 d 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 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 HARMLESS THE MUNICIPALITY AND ALL OF TTS AGENTS 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. APPLICANTS TU DATE lr/Y//C EXCAVAT�RORR IGNATURE(IF DIFFERENT) `\\\A DATE \,`V\�� OWNER'S SIGNATURE DIFFERENT) DATE: / ' aI 1 For mama ma rare—Oh awl +r riM tit dal . t WO It OPEtlafilitiree care e 2 of 2