HomeMy WebLinkAboutBldtr-20-001994 TOWN OF YARMOUTH
sO BUILDING DEPARTMENT Permit Number
p ' g y 1146 Route 28,South Yarmouth, MA 02664
508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
.
Expiation Date r w�9citt $50.00
TRENCH PERMIT
Pursuant to G.L.c.82A §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST HE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant
Ready Rooter Excavating Phoe. 508-888-6055 Cent 508-509-0802
Street Address
PO Box 89
City/i'own I MA ZIP
Forestdale I 02644
Name of Excavator lit different from applicant) phone c i
Street Address •
City/Town 1 MA I ZIP
Nowa°wnertslofProperty Elaine Cervone phone cei
Street Address 5 Danbury Street 401-556-4947
Citr/fown MA ZIP
South Yarmouth I 02664
Other Contact I Permit Fee Received No( ) Yea(X)
Daeription,location and purpose of proposed trench:
Please describe the exact location of the proposed trench and its purpose(Include a dgeriptlea of what is(or is intended)to
be laid in proposed trench les;pipes/cable lines etc..)Please use revere side it additlorad space is needed.
Install Title 5 septic system in rear of property.
OCT 10 201
i"""""'re(.ertineste+rs WC5-31 S-390198-19
Nara end Conte t lnforns.Hoa of km/re"Liberty Mutual Insurance PO Box 2027 Keene, NI1 0343-1-2127
Policy EAPiratlan Date: 04/15/2020
I me sa .* 2019-3606720
Name of Competent Person 1as defined by SIO CMR i-02):
Patrick Sullivan
Iof2
11/hurechusette Hoisting License F HE 144345
Liven r Crude: 2C 1 A _L+xpirstion Dale: 11/05/2019
BY SIGNING THIS FORM, THE APPLICANT, OWNER,AND EXCAVATOR ALL ACKNOWLEDGE CERTIFY
TEAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF TIM WORK.WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATION!
G.L. e. liIA,,fie CMt 7.00 et seq., AND ANT APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND
REGLLATIONS AND THEY COVENANT AND AGREE THAT ALL WORE 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 CONBTRIfCIEDN, AUTHORIZES PERSONS DULY APFOIN I1D BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORE FOR CONYORMTIY WITH THE
CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH WORE
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COATS AND EXPENSES INCURRED BY THE
MUNICCIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING BRIT NOT LIMITED TO ENFORCING THE IEQUIREMEiNTS MT 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 MEASURE;DEEMED
NECMISARY BY THE MUNICIPALITY.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDEMNIFY,AND 001.0 HARMLMS THE MUNICIPALITY AND ALL OF ITS AGMV7S AND EMPLOYEES FROM
ANY AND ALL LIABILITY,CAUSES OR ACTION,C06T2 AND EXPENSES RESULTING FROM OR ARISING OUT
OF ANY INJURY, DEATH. [ASS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNATURE
DATE, /0// 1 l
EXCAVATOR SIGNATURE tIF DIFFEREPIT)
DATE
O R'S N DIFFERENT)
DATE:
2 of Z