HomeMy WebLinkAboutTR-20-3312 •
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erl�D1N OF l'.�1RAIOlITH Z—aC�- 3/
C C DEP.�#RT1[ENT � l
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cj y 11.6 Route 28, South Yarntout , ,eta A266 Permit Number
I ext.i261 Fax Still-39g O336 Date Issued
' Expiration Date
$50.00
Pursuant to G.L. c; 82 TRENCH PERMIT
THIS p A §1 and 520 CMR 7.00 et$e9.(as amended)
PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSID
Name of Applicant/�r��` ��' A� eQ',,/ Pho ERA'ITON
Street Adder l.y �k7 G.�(.�(,t.� �-7' ne. p Cell
Cialfown ZIP
Name oft valor(if differpi from applicant) q
Street Add �;,J-��Lt,) ��Q,{, oOe •(,'el!
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cit wn
iiiimmmi
N tee of Ownerys)of Prn
r
fur
Street AddressC"PTA;
one . .Cell
cl3" de , "fie •
MA .
Other Contact
Ue��PI �location and purpose of proposed Pennri Fee Received No YesP pose+(trenche
be idd In proposed location of the Propo trench and its .
Please describe the exact
p posed trench tes;pipes/cable lines.ete.. Plea �°' (include a desert
1 use rererae lode it additional s(ion of what is(or is intended)to
Pace Is needed.
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Insurance Certificate it:
Name and C � 7iQ 9onfect Inton►w Inspirer:rer:
�t'is ate! L`7 , InA wt.e..
Poi
i Ex•iration Date. . ��''1� pig � •�� ..`�� `7
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Die c M:
.. Name of ompettol Person 1 • neal by 520 C'MR 7.O2)t
. 1 1 I. ' 4 or f /�L• /p
I _ e ..
.
Massachusetts Hoisting License# H Eo ge5 c JI a-I p-Og-0
License Grade: 4-1E. -, 1\ 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. e. BZA, 520 CMR 7.00 et 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 REGULATIONSGOVERING 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 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 WORK
CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNATURE `2
/ ifi i DATE Id-I
('9
EXCAUATOR�SpIGN RE(IF DIFFERENT)
Lla,..i1,e.(" V1 �� l tkli DATE I.21 1 b 119
OW R' SIGNATURE( DIFFERENT)
/� ___� DATE: 12-11 b 11` _
'. _-EnHt For elITIT u n sr --Da t write in this seetliwn
P.I&%T T Appian-
ppi i % i i'3 APp[icstion Fee
}PERMITI ING AUTHORITY D
(CO"lTI[I'ItON OF APPROVAL
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