HomeMy WebLinkAboutBldtr-20-001302 •
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��, t vrv1V OF "I ARMOUTH
. `� C t t-t6 B[l'LDINC DEP.ARTl1[EN'f ' Permit ' 2�--�362
H Route 28, South Yarmouth, MA 02664 umber
1� I~� .� i t)li'�370..
°'.►� r• 223 t 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 se
' • � ' � 9.(as amended)
TIIIS PERMrr MUST RE FULLY COMPLIED PRIOR TO CONSIDERATION
Name of Applicant
uL at'
Street Add " � "'' Phone Cell
C !i' NG 114. kc • . 3'�0/6 .p.4).119 $•3c'1 i+-10 J 0
wowttu ziP •
Name of Ergeivitor(if Ohms; applteant)
Street AdalG t;✓244,1 Q4, oOe CaU
Ci ' t ° 99-gal
Name of Owneria)of Pro
Street gd<gVAIr e DOMUCCM 0 Cell
ress '
n rr� �� �j xx
City/Town Y ((1�'��QGk W �b d�V� (0 1�(�
ufi11 \farm
Other Comm
Descript��locution and purpose oh pro trench:° t Fee Received No Yes
Please describe the met location of the ro
be laid in proposed trench( prslcakk lin ere..Plea p its (include adescriptionoralace at what is(or is intended)
eS;pi
ug mast Kide ft additions!apace Is needed.•
to• Y C
p 09 2019
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Insurance Certificate As nn�
IY1 fj
Name an
2d_Contact information of Insurer:
UoeIS aucf .6;/ IMrc s•a, .z. M
S.. Poi E. iration Dates. •���•��
a!f: ,r, j�,� ;
i-3col _ a-9•o
Dias Nr•
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., Name of ompetept person i • med by 520 C'MR 7.02)t
Massachusetts Hoisting License# n Eo ga 5$ //9-1 loo
License Grade: }•�E —;?-Pk Expiration Date: r
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. c. S2A, 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 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.
APPLI(ANT SIGNATURE
/J iefri �1a t �.,Q DATE �I 1
li
EXCAWATOR�SpIGN RE(IF DIFFERENT)DATE '119 I 1a I
OWNER'S SIGNATURE(IF DIFFERENT) r�
_ _.DATE: 9/V/24/1__
.
For ttefr .eise-•De h this seetkon
RY • Applicadon Frii`
I doNpallikti orAPPIDD%Ai.
4 •
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