HomeMy WebLinkAboutBldtr-20-001373 �.� off: TOWN OF YARMOUTH - _ 0/37)
4 BUILDING DEPARTMENT Permit Number
,/. .44''�`s� y 1146 Route 28,South Yarmouth,MA 02664
OI —
fC A -i ,y 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 Appikont' pt- •CA.)`C CO L lC• Phone Cell
Street Addren 2,4
Gre�.� 1. -l�c Y1 - , 8 �-t�Z o53C�
City/Town MA ZIP
<Th@S .,D Cn Camay
Name of Excavator tit different from applicant) Phone Cell
Street AddressY
City/Town MA I ZIP
Naas of Ownertal of Proper),Tao' ��0 Phase Cell
Street Address
'5 %O U C' LO-.
Cky/Town MA ZIP
Other Contact I Perndt Fee Received No(1 Yes( )
Deserlptios,location and purpose of proposal train
Please describe the exact loeatieta of the proposed trench and its purpose Iledeede a descriptie d.whatM
be laid in proposed trench 1 sf d
c'i pipes/cable lines etc..)Please use reverse side if eddltloneal a nted ., : H 4
t, 1ci
Insurance Certdkate Os
Name sad Contort Infortaatk,n of inrunr.
14 ub .zvm-e(Y)a.- or .` iueszz En3`04)0 -C-aWfr vne 1-0- recce
iSi" 7,0 - -Dkv
Name of Competent Penn 1 sa defined by 520(:M f T.Y2):
?,\ci\f0A \meNWIE ,
L of 2
Massschusetb Hoisting License l\ Ct-
•
License Grades Z A Expiration Date: 1
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 IEGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS`
G.I.. a ETA, SIS CMR 7.011 d sec. 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 WTTH THE CONDITIONS SET FORTH
BELOW.
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR TILE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO, FOR THE
DURATION OW 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 18ERRWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED
NECESSARY IT THE MUNICIPALITY.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
841DEIrINIFY,AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM
ANY AND ALL L ean'Y,CAUSES OR ACTION,COSTS.AND EXPENSES RESULTING FROM OR ARISING OW'
OF ANY INJURY. DEATH, LOSS. OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNATURE
DATE
EXCAVATOR SIGNATURE OF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
1st Cilifree• — ow wee
X-ri t i t ' s' Div S Isdkilppledies fat
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