HomeMy WebLinkAboutBldtr-20-003313 og: q . TOWN OF YARMOUTH
Y e BUILDING DEPARTMENT Permit Num
8(- d ,g y 1146 Route 28,South Yarmouth,MA 02664
•ti ,.,,T. .y r 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
Expiation D
$50.00
TRENCH PERMIT
Pursuant to G.L.c.82A 11 and 520 CMR 7.00 et seq.(aa amended)
THIS PER.MTT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Naps of Applicant f4-Cia,111 l�(k a l� Phone Cea
Street Addrei
City/Town J MA ZIP
Noon of Excavator Of different from applicant) Phone Cell
Street Address
City/Town MA I ZIP
Name of owners) Pre Phone Cell
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Other Contact 1 Permit Fee Revived No( l Yes( J
Descripdou,locales and purposr of proposed trench:
Please describe the exact Wades of the proposed trench and its purpose(include a description of what is(or is intended)to
be lid hi
proposed trench Mu pipe/cablees lens etc_)Please use revers silkif additional space la needed.
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Insurance Certificate h s
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ame sad Contact Information of lawr�f: ,1
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Pudly Expiration Date•. V 4
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I .Name of Competent Peron ins defined by SIR(Ml 7.112):
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Maatachinetts Hoisting License I )-1.L_P,"2/441
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License Grades `[. PC Expiration Date: A t a l ao
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 OSM REGULATIONS,
G.L e. CA, TM CMR 7.* et we.. 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 Ow 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 CONDUCT®THEREUNDER,
INCLUDING BUT NOT LIMITED Tea ENFORCING THE REQURBMENTE Or 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 Lam,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.
APPLICANT GNATURE
, c DATE Afb 9
EXCAV TOR SIG ATURE(TF DIFFERENT)
l DATE la j"1 ) i q
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
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