HomeMy WebLinkAboutTR-20-3392 .Y.. TOWN OF YARMOUTH aJ J?-Z(2--339 Z
# 4 BUILDING DEPARTMENT Permit Number
. 14, c 1146 Route 28,South Yarmouth,MA 02664
508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
**Niw" a. Expiation Date
$50.00
TRENCH PERMIT
Pursuant to G.L.c. 82A 11 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Now of Applicant,Rd y\ lie___\\(1L\- tense n,! CeN
Street Address � �,�611� �4,UIIJ
City/TowsJ MA �Si)' \\,()A MI:2p Ua ut`
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Naves of Excavator t f pp Phone Cell
Street Address
C;ity/Towa MA I ZIP CVA- taq
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Other Contact S'erCt�C�•J� ' I PermitFee Received No l 1 Yes( )
Description,
Fleece describe the exact location of the proposed trench and its purpose Dachas a descripdss of what is(or is intended)to
be laid in proposed trench Os;pipes lines etc..)Please use reverse side if additions'space is needed.
15 CW0\7111/4": Vac-i 1(6
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lasursnce Certificate»= Zzc_ii5 4 N (0G4, c)....1 ,
Name and Contact Information of insurer:
O-AMIViK ?MX! CCLA r\ . (-) Vo'6 ?
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!lance of Competent Person tas defined by 520 C'MR 7.Y2):
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Ikons Grades 4/Pt _Expiration Date: '"‘k
BY SIGNING THIS FORM,THE APPLICANT.OWNER,AND EXCAVATOR ALL ACENOWLEDGE AND cairrary
THAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF THE WORK,WilL BECOME FAMILIAR
wrni,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED.INCLUDING OSHA REGULATIONS,
G.L. e. SIS CMS 7.IS et seq.. AND ANY APPLICABLE MUNICIPAL ORDINANCES, SY-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 TIME
EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO, FOR THE
DURATION OF CONSTRUCTRA AUTHORIDIS PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND IMIPECT TUX WORK FOR CONFORMITY WT1111 THE
CONDITIONS ATTACHED Rum 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 BY THE
MUNICIPALITY IN CONNECTION WITH THIS PERMIT Ni)A THE WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT LIMITED TO ENFORCING THE UQVWEMENTS OF smut LAW AND CONDITIONS OF
THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE'1111121111T111,AND MEASURES TAKEN BY THE
MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO
COMPLY IIIIIRENITIN 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 OW ITS AGENTS AND EMPLOYEES FROM
ANY AND ALL umuunr,CAUSES OR ACTION,COSTS,AND EXPENSES RESULTING FROM OR ARISING OUT
OF ANY INJURY, DEATH, LOLA OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNATURE
DATE
EXCAVATOR SIGNATURE OF DIFFERENT)
DATIL
OWNER'S SIGNATURE Mr DIFFERENT)
/ uI(T721
/ DATE: /.) /3(A. °I1
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