HomeMy WebLinkAboutTR-20-2731 NTH . �.,or�-a c�--�3
�' YARMO Permit Number
TOW` OF
,,:�� � DEPARTMENT
.,`� by. Ati.t,. , ;�UILDI O MA 02664 Date Issued
\ i 1146 Route 28,South Yarmouth,
nS 398-2231 ext. 1261 Fax 508-398-0836
01 ya CVO' E.7,pi vim, c,,ii Da iz
4 ��. $50.00
TRENCH PERMIT amended)
Pursuant to G.L.c.82A 11 and 520 CMR 7.00 et seq.(
as UST BE FULLY COMPLETED PRIOR TO CONSIDERATION
THIS PERMIT M CeCellMane of Applicant R .c•-r 8 .0-`7 c 07 hone 3�''0'�l
Street L,-S : ••
Cit)flown _ ®^� _l. CeU
/J Phone e // 1
Name t . front applicant) f��' -��b"
of Ed °� (if different�„ Cu��1s
Street Address • rL),�
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4 ,,4,, M, oa,c-6
Phone Cell
Name of Ownsrlsi of Property A �1/�f q� 1- SO l�"_'91. g�(OV
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C�RIS
Street Address N /
Mown
Clall ZIP
' -'VA
A n A ^ N- //) 11411 D •• Permit Fee Received No Yes d what is(or is intended)to
Contact V 1description
Other Description,location and purpose of propsed trench: hand its purpose(Include
additional space to needed.
be the cram location of the proposed e..)Pieaee use rest'
Please describe cable lines ► b v,J y ♦ s4 Ci
be laid in proposed 1-1 trench leg;pipes/cable E'�
j 5���1V�N �� - D
tr 1� "ilk t ..�
� g NOV 12 2Q19
" D
: 11 ING DEPARTMENT
•
Insurance Certillcits N: 0.14 1 3 b i ' -p�
Vame and Contact inttsrmition of insurer:N�.c,1 .1J ) N • \ —
i
Pod F'�irition pate: 2,
Dig Safe N: 01 Q t 9_., L� 0 r P3
Mims of Competent Person las defined by 520 CMS 7.02):
I of 2
I
Maz=inuatts Hoisting Lireme# CJ D%6
•
License Grades a-k Expiration Date: S l ,
BY SIGNING THIS FORM, THE APPLICANT,OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WTTH,OR,BEFORE COMMENCEMENT OF THE WORK,WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,
G.L e. 82A, 52# CMR 7.0$ 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 REGULATIONS COVERING 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 SIG
DATE 100-1
EXCAVATOR SIGNATURE(IF DIFFERENT)
c/1) 4 DATE 'VA VA N
OWNER'S S NATURE(IF DIFFERENT)
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DATE. iil Uj l?
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