HomeMy WebLinkAboutBldtr-20-003311 441 ).'etr°,4
e Vr '1N OF YARMOUTHB[+tt.D11�C DEP:�RTt1[EN'f Permit Numbe -. 46-6°33/✓-_ `''Y1 ,. . r 1146 Route 28, Soutli '� .
Yarmouth, MA t)Z664
+ ,,,. :U8-398-223 I ext.1261 Fox 508-398-0836 Date Issued
• Expiration Date
$50.00 •
Pursuant to (� I, c' 82A TRENCH PERMIT
G.L. §I.and 520 CMR 7.00 e
• �' • . t seq.(as amended)
THIS PERMIT MUST BE FILLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant e tu` at, er p
Street A � �(,�,�•---! °e Cell
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Name of Etter(if diner
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PleasDescription)e location and purpose of pro Permit Fee Received No Yes
describe the exact location of the t trench:
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laid a tribe tee exact
trench cat pi proposed trench and its purpose(include a description
i calk Tines etc..)Pkaae pse rererse;i�id if addleton*,pnce of what '(or h intended)to
Vac'ie needed'
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insurance Certificate Its
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Name
and Contact information of insurer:
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Name of ompetei Person 1 .
` DD ned by 520 CMS7.U2);
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Massachusetts Hoisting License# H Eo geJ 5c I rx I icop-oLicense Grade: }}E. ,.
— 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. c. 82A, S20 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 TILE
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 ANDTHE-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
i l +.L'lik... DATE (\0 \el____
EXCA ATO,R�SpIGN URE(IF DIFFERENT)
4�/{� ia..e.,(- Vl �� � M ILUt DATE _142_41A_
OWNER'S&=:::
SIGN TURE(IF EFFERENT)
DATE: { V 2i/i q_
For(.14/fawn fro--Du not write in this stelrnn'
IPERMIT APPRO%-*E)BY r Application Fri
PERSIMING AUTHORITY fate
ICONDITIOMI OF APFRtri AL 4
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