HomeMy WebLinkAboutBldtr-20-003904 �� ,�o s I V VI'IN OF �'itRAiO[ITH t
aj , T 1I.16 tt.DINC DEPARTMENT pe46.-r12-20- 90-1t
N Route 28, South Yarmouth. MA 02664 Number
�\.:—.. '::: 44 los-398-2231 ex Fax 508-398-1
�` )s36 Date issued
' Expiration Date
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• . $50.00
' 'Pursuant to G.L. c: 82�,, 9,TREN� P�'KMIT
20 CMR 7.00 et se9•(as amended)
THIS PERMIT MUST RE FULLY COMPLETED PRIOR TO CONS
Name of Applicant CONSIDERATION
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Street Attdre� kJ(,LP.0 , � Cell
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Name of Exissivittor Ilt'diRerm from applicant)
Street Ada!
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Name or OwtK� ' 0Aty 5
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Oth Contact
De rlp location and purpose of Permit Fee Received No Yes
Please describe the exactproposed tsewtch.
be Isid in to location of the proposed trench and its
p posed trench(eS;Plpcafcahk linea•etc..)Please purpose tlncf ai ionari
• use reretae KiaQ 1r additional description of what i,(or Is intended)to
space is needed.
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Insurance Certificate lb
Name and Contact information oureo
D,� f Insurer:
! Poi Ex•iration Date: .ar' `'�� '�� "��]I "�
Die areM: 2tJ 630 ` � '! '
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tee , 1 •
Name of om
pe 1 Person 1 • med by 520 C:M1R 7.02):
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Massachusetts Hoisting License I! H Eo geJ D j J d-I /A-o)-0
License Grade: {-}E 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. 82A, 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 AM) INSPECT THE WORK FOR CONFORMITY WITH THE
CONDITIONS ATTACHED_HERETO-AND THE LAWS AND REGULATIONS COVERING SUCH WOFK
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
// 1/1rkdt-t. WI.W t DATE 114 11-0 �.
EXCAVATOR SIGN RE(IF DIFFERENT)
111141,0
' " ` DATE I
OWN ' ' SIGMA ,( D RENT)
DATE:
_ For Cit}/fuwn use--Du not write In this within
PF;RI►MrTAPPROVED BY _ 13 J Application Fri
PERMITTING AUTHORITY Dale
I Ct)'glil weAli or APPROVAL
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