HomeMy WebLinkAboutBldtr-20-001582 ,�r_ ;,K1Z-14; 11:54AM; I UVOJODVOJV
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TOWN OF YARM Permit Numt D CboSY
t * o�..Y BUILDING DEPARTMENT- °T.
° Date Issued
������ � XX46 Rontc'18,South Yarmouth,MA 02664
�, `":=�-�- ,� 508-39&2231 ext.1?.61 Fax 508-3�-0�6 �
. c- . Expiration Date /�
$5O.0O
TRENCH PERMIT 83 amended)Pursuant to G.L.c.82A 11 and 520 MLR 7.00 et seq.
TIUS PERMIT MUST BE FULLY COMP1E ED PRIOR TO CONSIDERATION
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Name of A�0.S C�� l�r1 - �\-� -LiSa`
Straee� . Email Address:S t at vrAnext 0
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City/Town A ZIP
Gkcw\On 0aGAS Mae Cell
Name of Execrator(if different from applicant)
Street Address S amt Email Address: l
MA ZIP
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Name rbone
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Street Address Email Address:
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1location and purpose proposed trench: to
of ��a of v►6at is(or is intended)Description,cribe�e�location of the proposed and its purpose(i
Is needed.
be laid in proposed trench(eg;pipes/cobk lines etc..)Plane we reverse aide if addition!spree
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Insurance C S: \r„t CC,`500 - 500 g`'�5,5 a 0,4 'A
t dame and Contact Information of Insurer•. Co.,�JL4�n�Yd� 'AVM g 1 i r1 \'{lA \Z d
I�Asscxc��e-c� �,p\ r s Tins _..
:Po • lion IWe:
Dig Safe f: a0\ 33 1.�366
Nome of Competent Person 19s defined by 52D CAR 7M):
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Limmtchoottas itoisdne Lkento• t--\ .— k 3 S 0 C ,C.)
' times*Grade: ac) _Expiration Data 1 I faS I ao\cif
BY SIGNING Till Mint THE APPLICANT,OWNER,AND EXCAVATOR ALL A4111:NOV/IETIGE AND CLEINY
Tiburviiity AIM FAIIIILLAR%TIN,OR,BEFOILE COMMENCEMENT OF TEE WORE,WEL BECOME FAMILIAR
ViLFELALIL LAWS AND REGUILATSCINS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS„
G.L. a SPA, S211 CUR 7.1111 at ,sq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND
REGULATIONS AP1D THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER TIllg PERMIT UNWED FOR
sut:ii viortic WILL COMPLY nizagwrre IN ALL RESPECTS AND wrra not CONDITIONS gET Foam
BELOW.
TML IPIDIERSIGNIZI OWNER AUTHORIZES THE APPLICANT TO APPLY FOR 1111 PERMIT AND THE
EXCAVATOR TO liNDEITTAICE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO, FOR 11111
DURATION OW CONSTItUCIVIN, AUTITOILTUM PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
El'ITER u10N THE PROPERTY TO MONITOR AND INSPIL111 THE WORK FOR COPIFORIIIITIT WrIll THE
M COPFIIONS ATTACKED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH WORK.
THEIBIDERSIGPM11 APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
agneeviss TIIII MUNICIPALITY volt ANY AND ALL COSTS AND EXPENSES INCIMItgl)BY TIM
AU .Y IN CONNECTION WITH THM PERMIT AND THE WORK CONDIJCTED TIESIMIJNDER,
INCLUDING Stir NOT LIMITED TO ENFORCING TIME IREQUUMIAISTMI OF STATE LAW AND COIMITIOPIS Or
THEIPILIMITT,MMPECTIONS PIADit TO ASSURE COMPLIANCE THEREWT/11,AND SIEASIFIES TAKEN SY THE
MIPACIPAISTY TOPIMIECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO
COIIIIPLY Iswrre INC'LLIIiING POLICE forrAas AND(mil:miaow.MEASURES IOUS=
NIICESSARITEY Tan MUNICIPALITY.
TIM UNDERSIGNZI/APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDIDIDEFY,APE)SOLD IIARSILESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM
ANY ALL tiAsuiry.CAUSES OR ACTION,COSTS ADM EXPIPISES RESULTING FROATOR ARMING OUT
OF ANY INJURY,,DEATH, LOIS, OR DAMAGE TO ANY PERSON 0R PROPERTY DURING TEE WORK
CONDUCTEDIJIVINIR'I'llIS rathirr.
A2PPLI SIGNATURE
DATE
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGNATURE t IF DIFFERENT)
, - DATE:
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