HomeMy WebLinkAboutBldtr-20-003221 '~ TOWN OF YARMOUTH 6
4 BUILDING DEPARTMENT Permit Number
ol �?Vg 1146 Route 28,South Yarmouth,MA 02664
„,r; �„;y 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
Expiation Dat
$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
Nave of Applicant ►' c " ,"b. OU i C C Phone Cell
Street Address 7.5i
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City/Tows I MA ZIP
Nave of Excavator Of different trorn applicant) Phone CellStreet Address
City/Town [MA ZIP
Name of Own.rr 'Property Phone'SnC�� � Cell
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City/['own MA ZIP
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Description.Wades and purpose of proposed trench:
Please describe the exact location of the proposed trench and its purpose(Include a deadpans at whet is(or is intended)to
be laid in proposed trench test pipes/cable fines eta.)Please use reverse!dde if additional space is needed.
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Insurance Certificate dh A 0 (L- 1— M
Name sad Contact information of Insurer:
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Po Expiration Doe: 1 I i I Zt -
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.`tame of Competent Person Ins defined by 520 t'SIR 7.02,: p
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License Grade ?,A Expiration Date: ) 12 fZO
BY SIGNING THIS FORM, THE APPLICANT,OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WTI'H,OR,BEFORE COMMENCEMENT OF THE WORK,WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED.INCLUDING OSHA REGULATION&
G L. e. ETA, S2S 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 FORTE
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 OR 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
MUNICIPAUTY IN CONNECTION Wn'a THIS PERMIT AND THE WORK CONDUCTED THEREUNDER.
INCLUDING RUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF
THIS PERMIT,iHSPECfONI MADE TO ASSURE COMPLIANCE TIIERBAIIH,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.
INDEMNITY,AND BOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM
ANY AND ALL LIABILITY,CAUSES OR ACTION,CATS,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.
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EXCAV pV I SIG TURE(IF DIFFERENT)
DATE
OWNER'ti TURE(IFD I -RENT)
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