HomeMy WebLinkAboutBldtr-20-003788 TOWN OF YARMOUTH
*o e;; _ BUILDING DEPARTMENT Permit Number ✓� 77f
(( r 4g y 1146 Route 28,South Yarmouth, MA 02664
.? ,,,,TM „ .w7' 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
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Expiration Date
$50.00
TRENCH PERMIT
Pursuant to C.L.c.82A I 1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Naar d Applicant I \ ' ( Phone Cell
Street Address �� Lout,
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Other Contact 1 Permit Fee Received No O Yes( 1
Description,location and purpose of proposes'teaueh:
Please describe flit exact Isadore d the proposed trench sad its purpose(Include a description of what le for Is intended)to
be Laid in proposed trench leg;pip Nees etc..)Please use remise dde If additional space is needed.
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Insurance Certificate ds fi06 .S
Yam)and Contact Information of Insurer:
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License Grad* 1!, `2 _ 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 BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATION„
G.L. a VA, 52* CMR 7.00 at 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 OWNS AND ALSO„ FOR THE
DURATION OF CONBTRUCTIOH AUTL PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INNPECT THE WORK FOR CONFORMITY WITH THE
CONDfIIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS COVERING 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 CONS WITH THIS PERMIT AND THE WORK CONDUCTEDTHERIUNIDER,
INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND common OR
THIS PERMIT,INSPECTLOPM MADE TO ASSUME 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 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 LABILITY,CAUSES OR ACTION,COSTS,AND EXPENSES RESULTING FROM OR ARMING OUT
OP ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
CANT SIGNATURE Vj(I,L__
l DATE _
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
4OWN R'S SI�GA N (IF DIFFERENT)
/6 Y/ DATE:
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