HomeMy WebLinkAboutBldtr-20-002385 TOWN OF YARMOUTH �/ 07e- -13
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„ BUILDING DEPARTMENT Permit Num. -
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1146 Route 28,South Yarmouth,MA 02664
c ,; 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
Name of Applicantcca ' eptipile)/
Phone Cell
Street Address p
<� 17�" ' 6i� ®` is- Email Address:
Cit(�y/Iown MA ZIP
Name of Excavator(if • erent from applicant) Phone Cell
Street Address p4.—
Email Address:
City/Town MA ZIP
Name of Owners)of PropertyMee&S &A4- Phone Cell
Street Address O
076 yeanos Ism Email Address:
City/Town MA ZIP
y4 Uia' I
Other Contact I Permit Fee Received No( 1 Yes(
Description,location and purpose of proposed trench:
Please describe the exact location oldie proposed trench and its purpose(include a description of what is(or is intended)to
be laid in proposed trench(eg;pipes/cable lines etc..)Please use reverse side if additional space is needed.
freati `cc°''C-
73e1L,1 .-2 - 46V) 641-4040, R E C I E D
OCT 28 2019
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BUILDING DEP/RTMENT
Insurance Certificate 0:
Name and Contact Information of Insurer:
"745109'6"-- (//
Policy Expiration Date:
Dig Safe IE:Z ZY C(yy / Q
Name of Competent Person(as defined by 520 CMR 712):
_r^�
1 ,
' Name of Competent Person(as defined by 520 CMR 7.02): ,,( ?
Massachusetts Hoisting License# 5—A—Q/�Uy(
License Grade: Expiration Date:
BY SIGNING THIS FORM, '1HH 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. 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 1'HI: MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE
CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS GOVERING 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.
APPL SIG
DATE lO 055
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE: