HomeMy WebLinkAboutTR-20-3183 TOWN OF YARMOUTH B(a(2-21)- �
og'Ya�4
} 4a. BUILDING DEPARTMENT Permit Number
��- ' 1 Yg y 1146 Route 28,South Yarmouth,MA 02664
./ 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
Expiration 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
Nacre of Applicant Phone
Ready Rooter Excavating 508-888-6055 cell 508-509-0802
Street Address
PO Box 89
City/lows MA ZIP
Forestdale 02644
Name of Excavator(if different from applicant) Phone Cey
Street Address
City/Town MA I ZIP
Name of Ownrsrlsl of Ptoperttstate of Susan Kennedy Phi" tell
Street Address
3 Charles Street 413-374-4373
Cky/Town MA I ZIP
South Yarmouth 02664
Other Contact I Permit Fee Received No( Yes(X)
Description.location and purpose of proposed trench
Please describe the exact location of the proposed trench and its purpose(Include a descripdea of what it(or is intended)to
be laid in proposed trench let;pipes/cable lines etc-)Please use mass:fide if additional space Is needed.
-W 3c r3
Insurance Certificate t+=WC5-31 S-390198-19
Name sad Contact information of Insurer.
Liberty Mutual Insurance PO Box 2027 Keene, NH 03431-2027
Pow Expiration Date 04/15/2020 -- -
iSikh et
12019-4606457
!yams of Competent Person as defined by 528 CMR1.M21:
Patrick T Sullivan
l of 2
0
►►iascb' s Hawn*Lkawe SHE 144345
[,items Gratin 2C 1 A Ex Dom, 11/05/2021
BY SIGNING THIS FORM, THE APPLICANT,OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
TEAT 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. e. SEA. 520 CMR 7.111 d seq. AND ANY APPLICABLE MUNICIPAL ORDINANCES •Y•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 OW COMITRUCOON, 'AUTHORIZES PERSONS DULY APPOEI TED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSECT 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
RE/BOURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE
MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING RLIT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF
THIS PERMIT,DISPECf7ONS MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES TAKEN SY THE
MUNICIPALITY TO PROTECT Till PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO
COMPLY THEREWITH II#NCLUDING`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 ITS 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 WORE
CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNATURE
—�- —-- DATE ,/ (�/(
EXCAVATOR SIGNATURE(IF DIFFERENT)
DAZE
O SIGN ILE 411(i)
ApokimaisAva
'I2. LT'tyi_ _' 11
2of2