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HomeMy WebLinkAboutBldtr-20-003273 YA TOWN OF YARMOUTH � 7�12— Zj e, o BUILDING DEPARTMENT Permit Number p( ''�!g y 1146 Route 28,South Yarmouth, MA 02664 ��MATTA M w'� 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued Expiration Date $50.00 TRENCH PERMIT Pursuant to G.L.c.82A 11 and 520 CMR 7.00 et seq.(as amended) IRIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant C4V o f sorb O u ti J � Cell Street Addressf ?7 6-a- 3c 7-(8•o 1 ts - 44.4.to-c,,,,-c-- s -r City/Town MA ZIP Name of Excavator(if different from applicant) Phone Cell Street Address CitydTown MA ZIP Name of Owners)of Property Phone Cell S�rp►T�k PAGi u t(.V Street Address Av Cky/rown MA I ZIP c5Oc t o w{c IMA o 1 (?Lt Other Contact I Permit Fee Rewired No C ) Yes l ) Description.location and purpose of proposed trench: Please describe the exact location of the proposed trench and its purpose(includes descripdoe of whet Is for is intended)to be laid in proposed trench lee:plpsskable lines etc..)Please use reverse!dde if additional apace Is needed. DEC O ) 2019 I Name and Contact information of insurer. i H- 4, Ccul -7'ro c AL c TH-0 C � rot Fspiradoq Dale? I a — i. Dig Sete N: /wig 4/0o al `o Name of Competent Person(as defined by 520('Jig 7.01): I oft • • Massachusetts Hoisting Lions*I E - ( 0103 -Ci - at1 License Grades — d1 A Expiration Date: 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 CA, 5211 CMR 7.00 et 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 WORE 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 MUNICiPAL[TY 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 OP ANY INJURY. DEATH, LOSS. OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORE CONDUCTED UNDER THIS PERMIT. APPLICANT SIGNATURE(�' DATE 1-q 6"a6 c1; EXCAVATOR SIGNA (IF DIFFERENT) DATE OWNER'S SIGNATURE(IF DIFFERENT) DATE: Far Maim -�„met V tli • ��t I„I ° ,, I. 1 ► t ► A4 2 of 2