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HomeMy WebLinkAboutBldtr-20-004409 `,* TOWN OF YA OUTHi BUILDING DEPARTMENT Permit Number C -.111 y y 1146 1 Route ,south Yarmouth k A 02664 .:', �. 50S-398.2231 ext. 1261 Fax 508 398-0836 Date Issued Fdtpirsition Date y $50.00 TRENCH PERMIT Pursuant to G.L.e.82A I I and 520 Chin 7.Ue►et seq.(aa amended) THIS PERMIT MUST BE Fl1LLY COMPLETED PRIOR TO corism IA'I"fDN Name of Appacad Sul C t' tarNn POosr Con a C4)6, ►. . Ser.ML trC .5t1 TI, -fit a5 t�,c� p� `«ra MA ' ZIP plsae of Laonritor Of Martel from ea nt) Phoa, cell Street Address' Cityffo ui, MA ZIP Naar et es". er 1Pt weey fbasWk r16 Cc,net©5: P cos Street AddressiG/y 3 y ^- � aaa Q )c\h S citylrowo MA ZIP •iar mookan oar Other Ceatack I Rene Nisi. lived N.t .�Yes( ) DeetelPelell.leallaleal and psopent orproprow treaeb Pie+.o dearer**the ese#:heathel ell*propelled french and Its pacpist(istiolgto a be iaid iN dmct space Is rink I.tor is iatea to !re'PwJ tteacp,4 P etc..) . t restate'wile it l space Is aeaMd .rc- r,.sf.a,ft .‘"re w '.ru0,4 c S$- r7_i ./I 04=7"•G. p7`' $ems, era/•s,��` 7, 4/ cs:ac.e►e',jam... . ?O2I. C. RTMEM,"'- } By Instir$tte t rli kst.tft Nome IladContact Ingbilaslien.1Ia unr Oow\`r - O'Ne \ Ir r'c ce 1 Pp . 1qq cyan 5 cr\ C1Rt O k Potle7 Etpirstlon:Date! C i a/On .-. ao - Gl2O5740 1 Niel"of Ci+mpete e feriae iae fee deflect,It"Sl$C M*tea: ' , , 204 1\ 'f \r I-N I of fkl ♦. • hIssockaiNs Ilektlfig Limon./ 1AE O6 atct 1 SY SIGNING.'Ns maw'nor APPLICANT,OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY TEAT`THEY ARE FAMILIAR WM,OR,ARE COMMENCEMENT OF THE WORT,WILL BECOME FAMILIAR Wes,ALL LAWS AND REGULAUOND APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIO , G.L. e, PA, Sb CM* TAB d se},. AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY.LAWS AND MUTATIONS AND THEY COVENANT Ate AGREE THAT ALL WORK DOME UNDER THE PERMIT ISSUED FOR SUCH WORK WILL COMPLY THEREWITH IN ALL RESPIXTS AND WITH THE CONDTITOIR# SET FORTS *FLOW. THE UNDERSIGNED OWNER AuTRORms THE APNJCANT To APPLY FOR THt PERMIT AND TIE cAYATOR Tt UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO, FOR THE DURATION OF CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO ENTER UPON TNT PROPERTY TO MONK AND DEN= THE WORK FOR CONFORMITY WITH Tag CONDITION Amami VETO AND THE LAWS AND REGULATIONS COVERING SUCH Wes. THE INDESPGNIIIAPPLLI ANT,OWNER AND EXCAVATORAGUE JOINTLYANIISEYERALLYTO MUNICIPALITY NI U A Y F ANY'AND ALL CMS AND NOR IT LTRIt IN comontorwi wue TRU P AND TIP WORK CONDUCTED'TTiERI Ut I, INCLUDING BUT NOTLIMITEDTO ENFORCING THE*EQUIREMEN IE Of STATE LAW AND COMMONS OF THIS revar•DVIptcnOP11 MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES TAKEN BY THE MUNICIPALITY TO PROPICT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS TAILED TO COMPLY IISIDIEWTIBI INCLUDING POLICE DETAILS AND OTHE!REMEDIAL MEASURES DEEMED NECESSARY IT THE MUNICIPALITY. THE IJNDEIMIGNIED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY Ate SEVERALLY WI DEftE % INDRMNWY,AND HOLD 0AJ4Ii THE MUNICIPALITY AND Aug(JV Its.AGENTS AND'EMPLOYEES FROM ANY AND ALL LIABILITY,CAUM=OR ACC cane.AND MIMES REPILTING.PROM OR Anne GUT OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER TID$PEEMFI. APPLICANT SIGNA DATE -J',</ d EXCAVATOR SIGNATURE(IF DIFFERENT) DATE OWNER'S SIGNATURE(IF DIFFERENT) DATE,. r a ) > r o,. a 2 of CERTIFICATE OF LIABILITY INSURANCE DATE(MM/ODIYYYy) , . FI NOT R A MA O!�MA Or IPWORMA I'a L r A «• A.r e r r S Cl':RTI lVFERB NO RIGHTS UPON !`1 DOES OTAPPI UA'tQ s T TIVELYAmEND,!XTltplttORALT! , ECOVERA `AFFORDEDTt;A a .I VE `�: •• 7' TE A CONTRACT BETWEEN THE 1 IING INSURRS) T O THE POLICIES NTATIV... MPORTANT:lithe Certificate A �• - �, 1 �,,� i . 0, A �: ��,AG�IHORIZED�REpRE�IE INSURED,Imam ADDITIONAL lees and condition of dat PollOY,Olden ROWSE MEV WHESTiatni enclonannent A StiesMent On this certificate does not confer rights to the PRODUCER DOWLING&O NEIL INS comet 973 IYA NNOUG3H RD HYANNIS,MA 02601BAAL 22LGRADDRESt PI$URED ,- ATEMUCA CAPE COD SEPTIC SERVICES INC NOURERA: ThAvar,"✓ aB T�tCASUALTY COMPANY r INSURER 5: INSURaB C1 350 MAIN STREET atauR o: WEST YARMOUTH,MA 02673 INSURER : COYERAOEB INSURER I I: , C 111PICATL NUMB R: ANY S . .,. ' ,A,e , ,- , , REVIE IN47NAER•. i lENf,TER*DR W ti ,, - AmREca BYTICFRCM� CQ�TIONoFARVRONTR rOR 40CLBIE,rMTH O TO I HT' A T,r t AR •CERTIFICATE HAT ES O �=•*. PERTAIN.I -r.-. ANC,r ARID RDECLAD , H IS T'TO ALL T E murk EXCLt � j OF SUCH PO IO.LEST'SHOWN A,iY HAVE BEeNTRBD EY INSR Woutam LTR TYPE DANCEFOUST NUMBER gum y DATE yy) GENERAL LIABo 1TY LINTS $ MI COMMERCIAL GENERAL LIABILtr'Y CiGCUFtR1:TE $ r gi CLAIMS MADE [J OCCUR • TO RENTED REMISES Eel;pccurcerce) ED EXP(Arty on person) $ GENt AGGREGATE LIMIT APPLIES PER: •ERSONAL 8,AD1/INJURY $ S POLICY 0 PROJECT'0 LOG ENBRAC AGGREGATE AUTOWERS usedu Y •RODUGTS•C9Ml'/OP AGR $ ANY AUTO ©ST Esa SINGLE $ III ALL OWNED AUTOS ODI E JURY t al 1111 SCHEDULE AUTOS •OD1LYIJURY $ I HIRED AUTOS Person) MI NON*QWNEDAU'I'Q,g BODILY INJURY - •er accident) 'ROP -TT DAMAGE $ Per ecadent) IIII Ill UMBRELIA LIAO" allOCCuR al Ecorse LIAB NI cWM cccuRReNc in DEDUCTIB� �rcTi7;.OATS. $ $ . RETENTION • A WORKER%CO PIMSA TION AND s IMIPLOYER'BLUABIUTY YIN 4JB�8H09 .19 06121201 wCTSATUTORY nee ANY PROFERITOR.PARTtSRtp JIVE 06J12tZt12bEll LIMITS OFFICERNEmEER excLu EDT NIA 5 + +ry r pe E.L.EACH ACCIDENT $ 500,000 n 'tleP E.L.DISEASE-EA EMPLOYEE ; 500,000 ydsmoDes(�iIPTION OF OPERATION&Wow DESCRIPTION OF OPERATIOF/811.00AlIONB�IVRN I.E E.L.DISEASE-POLICY Lam $ 500,000 nos REPLACER ART PR�ii RICSoNOIOPEGIAL riliihn 4TE 7BDTO TAN=Motu soixectAnacmre Woiozo.5 cow con cons-AGE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED FORE THE BxPIRATIOH DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCYPROVISIONB. AUT1"--"-lr----"'— ---""---"'"—"RIZEEO RPpRlB VE ACORD 25(2010/05) The ACORD name and loge are retilstered marks o ACORD 19864010.ACORD IDQRPO ON. Ai1HDM;.ro:orvyd r