HomeMy WebLinkAboutBltr-20-002649 !(
W=,) �o BUILDING DEP�o.RT'MEN I Permit Number
� ,�� c 1146 Route 28 South Yarmouth, MA 02664
%`:: „` t� . 508-398-2231 ext. 261 Fax 508-398-0836 Da e Issued==w- ' •
Expiration Date
TRENCH PERMIT
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPJL.FTED PRIOR TO CONSIDERATION
Name of Applicant &r'1 i 11 (2 ,s _ / - C' -Phone Cell
Street Address 4 5 inaiuokc- WRd L�� v — '� — 3�j
CitylTown MA ZIP •
VtiIcwoM V4, v �c4 4 S
Name of Excavator(if different from applicant) Phone Cell
Street Address
City/Town MA ' ZIP '
Name of Owner(s)of Property PL Phone Cell
M CA J Street Address Sod-362 //�
- /8'1 3
QS U La) p
City/Town MA ZIP
Other Contact Permit Fee Received No c ) Yes( )
Description,location and purpose of proposed trench: ksAk prt°j A.t., n ..6021-uxd houor 4 a. .
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.
4ttio,,,ud¢, 7r6 Ek 1 V I. A,a t efv, 6.X ) 2 - 410 500 c J lie. ,0_b n'Yt.Qi-- )
a ,)-s' X i a.S3' sec V$ev'.ecC, C v»,2e.J (— f u ,s2-ix.l s H A 5.rirt-e, . n1
NOV 'Th '01
Insurance Certificate#: 62,05S 42.33 _)
too 3(G i 1' RTM NJT
Name and Contact Information of Insurer: ..ectleibitzt ) j_viSu
t —33'3- L(g49 Pv. eX,4 3A&
OLLIOLA o r\0. t M tit 5-5-C'CP C)Policy Expiration Date: 3 ('"" `Avg
Dig Safe#: tO,1tiSo so 1 L
Name of Competent Person(as defined by 520 CMR 7.02):
1 of 2
Mas: _iiasetts Hoisting License# /34 tic" //y l�
License Grade: Expiration Date:
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 BECt%ME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE'TO WORK PROPOSED,INCLUDING OSHA REGULATI NS,
G.L. c. g2A, 520 CMR 7.00 et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, :Y-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 TEE
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'I'HIr.REWITH,AND MEASURES TAKEN BY THE
MUNIC'I'ALITY TO PROI•LCT THE PUBLIC WHERE THE APPLICANT OWNER 0,,. EXCAVATOR HAS FAILED TO
COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED
NECESSARY BY THE IVIUNIC!I ALITY.
TEE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDEMNITN Y, AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYE:FS 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 WOE"K
CONDUCI"E:I' UNDER THIS PERMIT.
APPLICANT S AT
DAf l/ 19
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE f/`,
OWNER'S SIGNATURE(IF DIFFERENT)
,r'724 7/q DA I• .: I I C a. I
- For Cnt`l6'qwce use.—Do flat write irit(INS'se+ct oar,...
PERMIT APPROVED B - Applicmo Bias ..::
P R_MITUNG AUTEIORIT ' . Oe`.. = -'
CONDITIONS O)r APPROVAL: _ .
•
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