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Home My WebLink AboutBldtr-20-002140 TOWN OF YARMOUTH ( (11529 -'-2,o--toZI BUILDING DEPARTMENT Permit Number C 1146 Route 28,South Yarmouth,MA 02664 „„ ,;c„ c 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued - "4..gMno`0'End Expiration Date $50.00 TRENCH PERMIT Pursuant to G.L. c.82A §1 and 520 CMR 7.00 et seq.(as amended) Tins PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant(Fir)1 1 - k , (nC . Phone Cell Cell Street Address bo ryy I d5 �'8-CA 5� Email Address. aff(6e,litnexenv a City/Town MA ZIP Dinnis ( 2 Name of Excavator(if different from applicant) Phone Cell Street Address ,,,��,o SlabV t�— Email Address: City/Town MA ZIP Name of Ownerls)of Property I I mn ri n Phone Cell Street Address l� ��'�� Mau( , a f OU l l lr Email Address: City/To MA ZIP oacoo4 Other Contact ) Permit Fee Received No( ) Yes ') Description,location and purpose of proposed trench: Please describe the exact location of the proposed trench and its purpose(include a description of what is(or is intended)to be laid in proposed trench(eg;pipes/cable lines etc..)Please use reverse side if additional space is needed. C(6L 1 I73 See Ptched insurance Certificate 1: Name and Contact Information of insurer. . Policy Expiration Date:Dig Safef: aon- qaor-1515 Name of Competent Person Ias defined by 520 C'MR 7.02): irccc rnmis . ' Name of Competent Person(as defined by 520 CMR 7.02): n Massachusetts Hoisting License# 1 v—o rig(,)41 License Grade: Expiration Date: • I D °KJ 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, 520 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 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 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 !'HEREWITH,AND MEASURES TAKEN BY THE MUNICIPALITY TO PROTECT THE PUBLIC WHERE Mk.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. APPLICANT SIGNATURE Lett.A..669.11,70. DATE 0 I IC )9 EXCAVATOR SIGNATURE(IF DIFFERENT) DATE O R'S SI N TURE(IF DIFFERENT) 1 (LthfYk2 DATE: ID )10 n .tiw �• t L', ^'+,_ - }'°h>' `Fli - .s�r" ,A-^ wr. a t- — rrrr rr T- f ."_ , ' �� = — � a"� 4 Lan w+ "`�- k 4v.-, .+vim"°_'--• "�` -+_ �,. .. _V7- S. �..NN GFMEN-1 OP ID: KT ACORO` DATE(MM/DD/YYYY) `--- CERTIFICATE OF LIABILITY INSURANCE 08/14/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Eastern States Insurance NAME: Agency,Inc. (A/C, Ext):781-642-9000 FAX,No):781-647-3670 50 Prospect Street A DRESS:certificaterequest@esia.com Waltham,MA 02453 INSURER(S)AFFORDING COVERAGE _ NAIC N INSURER A:Ohio Security Insurance Co 24082 INSURED GFM Enterprises Inc. INSURER B:Acadia Insurance Company 31325 P.O.Box 1439 S Dennis,MA 02660 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL BUBR POLICY EFF POLICY EXP W LIMITS LTR INSD VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE _$ 1,000,000 CLAIMS-MADE X OCCUR BKS58044964 06/15/2019 06/15/2020 DAMAGE i O RENTED 300,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X JE- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) A ANY AUTO BAS 58044964 06/15/2019 06/15/2020 BODILY INJURY(Per person) $ — ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE $ X HIRED AUTOS X NON-0OSWNED (Per accident) AUTOS $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A - EXCESS LIAB CLAIMS-MADE USO 58044964 06/15/2019 06/15/2020 AGGREGATE $ 5,000,000 DED X RETENTION$ 10000 $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y A ANY PROPRIETOR/PARTNER/EXECUTIVE N N/A XW058044964 06/15/2019 06/15/2020 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If Yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 B Equipment Floater CIM5308293 06/15/2019 06/08/2020 Own/Leas 1,690,414 Rented 25,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION YARMOMA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE --- .,..s.r-,-------- -- ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD