HomeMy WebLinkAboutTR-20-1301 .l'*1
i v WlV OF lr ARMOUTHn, �I 0 !WILDING DEPARTMENT �� ���/
Permit um6�r ��} y 1146 Route 28. South Yarmouth. MA 02664
p 1 ext.1261 Fax S(18-3t)S-Utt36 Date Issued
Expiration Date
. $50.00 •
Pursuant to G.L. c; 82A,TRENCH PERMIT
and 520 CMR 7.00 et' • '�1 seq.(as amended)
THIS PERMrr MUST BE FILLY COMI'IXTED PRIOR TO CONSIDERATION
ON
Street C!lt, , Gv�,d erth�'�; - Phone
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Name of E valor it ' ' V ��3 1
( diillterp from applicant)
Street Adat� eleUeLe T �;, .5,(.`i.Q.QA, Phone •
Cell
Name of OWeew 0 fy S
ner%)o Property
8lreet Adtlre.i/i �ah+eext Phone
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City/l'owtr �J00 •9,7o` -70/
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Description,location andpose Pe t p' Received No
Pleaee describe the exact location tof e proposed trench: Y�
be lald in pribe the enact
trenchl(eat pi of the
liner trench
its purpose(include a description
!fie reverse�11*additional �what�(or�intended)to
space Is needed.
•
Insurance Certificate Mr v
Nana and
,Contact information of Insurer: p
• Po Ra•iratton Dates. S �l f .."� `I
'.�i ' '^ ,
Dies tit: ' • •
Name of empetept Person 1
mod by 520(MR 7.02)s
t.„
e
. PS .
Ma.dtasetts Hoisting License 8 H Eo 065-S S f/ .j / -o .o
License Grade: E —Ate Expiation Dar:
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. a 81A, S28 CMR 7.00 et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS ANTI
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 TILE
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 TILE LAWS AND REGULATIONS GOVERI NG 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 N(Yr L MITED 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 TEE 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 BOLD HARMLESS SS 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.
APPLICANTSIGNATURE "
&' --- DATE V I IIY 11 q
EXCA ATOR,SQIG (IF DIFFERENT)
• V1 wl DATE e i(419
O 'S SIGNATURE IFFE'
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I PERMIT APPRU TEDR1 r 3;:....._ Fes
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