HomeMy WebLinkAboutTR-20-3839 t4' • `Y' TOWN t F ' AR # UTI c ri
/ ' S BUILDING DEPARTMENT Permit Num er 7 r6 + ..3g
-33
c .\,s
1146 Route Zvi,South Yarmouth,MA 02664
?_ , • A 4 508-398. 31 ext. 1261 Fax 508-398•083 6 Date Issued
♦ Y.
- Expiration Date
$50.00
TRENCH PERMIT
Pursuant to G.L.c. 82A ;1 and 520 Ch R 7.00 et seq.(as amended)
Intl Prot Yin MUST OS MIS COI‘SPEEnD PRIOR TO COIVPittEltAlltnt
Naeae st Apptksnt ut C. rvY n Plaae Cod
Addrts 41.c ` tc. berv`(-Ab trC. °5t3g 7T5- ►t a
Straitb6e) (�,tsot
CCtyIT.we. MA ZIP
Name of Excar#ar Of dtftlersat them Wit) non. 'ell
Street Address
ctepfrow�a MA ziP
N at ty s)of ,phonecar
S ie,° P C
sereett )+ t _ 000
►'2aq t),-
coy/rows - MA zpr
Other Contact CP,rmit Fes Rcoiso2l Ns )' Yes t )
tUoscrtp hcatto�e am peen of prope.d#reecht
aexacttaeadoa of dw +opveed Ireesr6 sad rb parpaee(Inelai a deaedpdoa d what I.tor.ts Intended)to l to proposed trench test POPleittnhle Bile*rte..)Phase use rtrerae add*Ifsdrddon.I space Is suedett
C.- `sys 7`t"%ke-r /-, r'S/a t cr or4/ .
i troserttnrit CertdicNe Its
0()3 •40 \3c qq- 1 q
Na*oat Contort I$fsi esttoa of tonere,' Oo M s,G *- Q`1Je! I rrc
I Pa IGQQ ctnr,°s c� Gt►cat
'P•100 ffejoirstten Pate: 1 t 211 aQ'Dig SeSt lit
aOaC) -6&y q5
1 Y anti Olt CC+anpet.NI Perae tud ttnod by$2i t:MA 7,02ts
90k 1` inns\`;
I of
Mumsdhamdtsnab*,L Limos IA E. O2 g25i
• Gtld�t 1 C a
• tierce � q, Dotef' J1 ewe
BY SIGNING TH$PORK THE APPLICANT,OWNER.AND EXCAVATOR ALL ACENOWLBDGE AND CERTIFY
THAT THEY ARE EAMH.1AR MTl7I.OR.BEFORE COMiCEMENT VE THE WOE WILL BECOME FAMILIAR
WTTR.ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSE%INCLUDING OSHA REGULATI
EA, 520 CMR Tie et silo AND ANY A PPL+ ABLE MUNICIPAL ORDNANCE% BYLAWS AND
REGULATIONS AND THEY COVENANT AND AGREE THAT AU.WORK DONE UNDER THE PERMIT ISSUED FOR
SUCH WORD WILL COMPLY THEUWTTtI IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH
BELOW.
THE UNDERSIGNED OWNER AUTDOEIXES TM APPLICANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WORK ON Tilt PROPERTY Of THE OWNER. AND ALSO, FOR THE
DURATION Of COPIIMI TCTION AUTHORIZES PERSONS DULY APPOINTED SY THE MUNICII►ALTIT TO
ENTER UP4NTIM
PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONIORIRTY WITH THE.
CONDITIONS ATTACHED nacre AND THE LAWS AND REGULATION COVERING SUCH WORE,
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REIMBURSE THE MUNK:PAL:TV FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE
MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND=WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT LIMITED TO ENFORCING RIDQVIREMENIS Or STATE LAW AND COMMONS OP'
�
," 'P*M AS COMPLIANCEITE
THERE ,AND MEASURES TA N N BY' E PUBLIC WHERETHE APPLICANT OWNER 0*EXCAVATOR HAS FAQ TO
COMPLY TIODREWITII INCLUDING POLICE DETAILS AND OMER REMEDIAL MEASURES DIMMEDNAY ST TITS MUNICIPALITY.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DmN,,
INDEMNIFY,AND HOLD HARSH, MS THE MUNICIPALITY AND ALL OF ITS AGENTS AND IMPLOYRS FROM
ANY AND ALL LAJILITY,CAUSES OR ACTION,COSTS,AND MENSES RESULTING FROM OR ARIBIEIG OUT
OF ANY INJURY, DEATN, LOw OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER nos P MYT.
APPLICANT SIGNA
.tc. ,.000" DATE //
P _/
mod
EXCAVATOR SIGNATURE CIF DIFFERENT)
DA'
OWNER'S SIGNATIJRE LIT DIFFERENT
DATE:
4
2 of 2
CERTIFICATE OF LIA=ILITy INSURANCE
�." .� r ►Ta+ ►ssu Ati a�A ' �►� D1YrrY„.• •- :a�ICATE T • I f. .• o Y .C1 ,.DO NOTAFFl A y R i OR�u. c CVMx AP - .., , ,
THIS! ' TIMCq"�`.tyF IAIiiIJI�IINtig p�',� �
COV RAt AFFpRDED BY THE REPRERENT TI
�, 1 ,, 1 ...� N THEBURNNO tN 6.UFtf g AfJTkOI#Z A-1tRRlRL N7"A �
Mi'GitTA1NT:flbta ssrttil�ata twfder ADW?TCINAf.1NaU_
BIfR;,and aanf them tf-.tnr o hol�t•awn pit e8 maythe I )muse 4a i; 1 tlBR
finite holder In Neu of s s ... grand Indorsement,A statement on this �lSerm nit confer
ig is to to�t
FCbitCEW!' a aC�s+�c 'ri net rights to the
DOWLING&O'NEII.INS
FAX
973 ITANNOUON RD
WE.NoN
IIYANNIS,MA 02601 6,rfN1q,
22LOR. Atones:
INSURED BlsUR AFFORDING cOYr .
CAPE COD SEPTIC SERVICES'INC *SUM A: TISA�FRQ 'CASUALTY COMPANY OF ,� .
INSURER IR
INSURER C:
350 MAW STREET stssU D:
YARMOUTH,MA 02673
WESTINSUR R is
s ieLtAct V INWRER F;
TTRt NUS
/yam ",�r��*
AN �y�� /yam RC� d '`�*4}.�.nM.w4i\*1..Ett .a.SRAY SE- -.- '^"'
AFFOR eDBY t( 1 PAID CLARLe. HERD! suBJ To4141.'l r� NT VMYFl 1lMF. gOF'Maw dt.LIINTS1UEt?CR MAY AVE BE RED
BIER . ,
e ►MRI MAY HAVE BEEN, REDUCED, BY
LTR WFS l Iry B 111.311 • POLICY NUMBdt ( D QATL°
MICEASAERCIAL GENERAL LIASILITrro Loma
H OCCURRENCE $
CLAIMS MADE CD OAR IS TO RENTED' $
®al •REMISES Ee ercu ranee)
iDell
ADORBOATEUNIT APPLIES PER: E7CR(Anyr eee psnon) E-
ERSDNAL&ADEGAT RY` $.POLICY ElPROJECT 3I"o ERAiLAfI REQATE
AUTO/loop,gLASI RODIIC7s.COMR6f1PAQ0 t
U ANY AUTO C)IIIB$IED SINGLE
IIII ALL OWNED AUTOS DI(Ea eC $
® SCHEDULE AUTOS BODILY INJURY
NI HIRED AUTOS ' person)INJURY•S NEjIEDAUTO, BODILY
•onto***
a
Re?Pal
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IS UMBRELLA IJAB II.OCCUR
mg moss LI 8 ®OLAIMSNADE • f1CCURRENCs $
MI DEDUCTIBLE rT r , Pr, 6
Nil RETENTION
A WtNtif�lle'M cos eu A n NM AND $
BNPLOYER YIN UB-BH089es i$ •08r121201$ ® ,,vcS ATPTORY OTHER
ANY'ORtiPEtliTORFMTNrB71 urIve QCJ1211�20
AN YCettemwORexcL Magri N Nth
STY le N►il B.L.EACII.ACCIR ► 500 000
tscIt ds• oF0 E.L.gtSEgsE•MEMPLOYEE-
IPtpNOFOPERATfCiNPdabwt $00.000
i
DE8Ctep►tiprl or pt+ERp1II tBAtICATbl1611I1:W�undv
E:L.q 0•PO Y uMrT $ 500,000'
'� ttS ANY YREOR RST'tgC'f101ds/Sl•ECiA6 nos
9N MUFF!TO TgI aTip CATEROTOBSAFFECISIO WORSISS5 Cam,COyERA ;
CERTIFICATE HOLDER
:OANCEi.LA1tON
SLR ANYANYtermiABOVE OEe g*km*as CANCE1.L
Wt NTION WON THRRISOF,Nowt waltS,cowmen)
CRMY_ 7HIS.FOLIDYSIOVIsKOHE
AUTHORIZED RtfPRks14N yR
1 . ,�
ACORD 2810lD6 ,p,,,;
I me ACORD name and logo*reregistered mar a ADO.RD
t9S6-, 0 ADpRO PQRRQON, All rightsraserve `
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