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HomeMy WebLinkAboutBldtr-20-004002 . dlit TOWN OF YARMOUTH �Lbt2- D-L1 Oct. 4`" � � BUILDING DEPARTMENT Permit Number e 1146 Route 28,South Yarmouth,MA 02664 t' . 508.398.223'1 ext. 1261 Fax 508-398-8836 Date Issued Expiation Date $50.00 TRENCH PERMIT Pursuant to G.L.c.$2A II and 520 CMR 7.00 et seq.(as emended) TIlLS PUMrt MUST en FULLY COIVIPLETILD PRIOR TO COI4SiDI►1ATR)N Name et Applicant SL C Ct-v -'1c Phone Ced Street C L0 r. b r LCb r C, bg-t7.5- €�a5 b6Q. t) , CitylTo+vn MA ZIP ------... ori,1r 0atl Nam of Excavator(it different home eft) Phone Cep Street Address CityRowq MA ZIP Nean of Ownerlel of Ptopn#yr Phone Cell Street Addreri eor5Q c ' -70D-7a5-�S 1 yO VJU r Or City/nitro MA ZIP 1,0 n Oa ether Cam; y ucrDI Permit Fee R,cdsed Not )`Yes( Deeerlpth ivaWeo sod purpose et proposed trench descrle the esaet location.et the proposed trench sad its poops*(Include a deseriptless of oboe le(or is Intended)to be laid In propelled trench test pIpeofuhle lines etc..)Please sore Aim , Ids If additional -- �s fit/ ,�Gce/ ,r,,-"4'7ee G sysfr�r i fi-t ' '; ': E ! ‘l' 1 2nI! aN g E , IBU;Ll ,. a � ,l ; .iv:_N7 By insurance Certificate Nn {{}},, ,,`` Vnnr end Contact lostnneetion of bonnets 0 ,, PO c 1ggG 1 p 1t1°r-NJb 'Cr c; Cla4)0 : Policy Fxptrstion PaIr- 5-//a l aoaC) Dledt ,vaostotc, c•Ua(� - ` otz \ 1 :mpetent Peroos les defined by 52(.MR tat,: 2n.,,1\ 'c1 r c al '3 Iof2 Musschusets Liam. E o 23agvI • u .cam«, Ac,ace► Xrpiredoce Data 51Z,%1,Qoa\ BY SIGNING yws 113104 THE APPLICANT,OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT mazy AAE FAMILIAR WITH,OR,BARE COMMENCEMENT OF THE WORK,WILL BECOME FAMilIAR Wrru,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED.iINCLUDDYG OSHA REGULATION G.L. e. SVC. 520 CMR 7.10 eat seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BYLAWS AND REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORE DONE UNDER THE P RMTT ISSUED FOR SUCH WORK WILL COMPLY THEREWTTN IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH BELOW. THE UNDERSIGNED OWNER AUTHNJR'ZEB THE APPLICANT TO APPLY FOR THE PERMaT AND THE EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY Of THE OWNER, AND ALSO, FOR THE DURATION OF CONSTRUE AUTIOORIZTlB PERSONS DULY APPOINTED BY THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MON 'TOR AND DifIPIECT THE WORK FOR CQNiP31TM.rry WTI'R THE CONDITIONS ATTACHED HERETO AND THE LAWS AND REGUIATIONS COVERING SUCH WORE.' THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES`INCURRED BY THE MUNICIPALITT TN CONNECrIONN WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNTDER, INCLUDING BUT NOT LIMITED TO ENFORCING THE MEQUIREEMEMI OF STATE LAW AND CONDITIONS OP THIS"KRM17,INSPECTION;;MADE TO ASSURE COSIPLIANCE TIIEREIIYTTLi.AND MEASURES TAKEN BY ME MUNICIPALtry TO PROTECT TEE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FARE)To COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES OWNED NECESSARY BY TES MUJNICIIALrFY. THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND, TNDBMMNIFY,ACD HOLD HARMLiS THE MUNICIPALITY AND ALL.OF ITS AGENTS MD EMPLOYERS FROM ANY AND ALL LIABILITY,CAUSES OR ACTION,C'tki TI, AND EXPEKSFS RESULTING FROM OR ARMING our OP` ANY INJURY, DEATH, LOSS. OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PTRNIIT. APPLICANT SIGNA1JtRi ,. DATE /,%i, *© EXCAVATOR SIGNATURE CIF DOVE/TENT) DATE OWNER'S SIGNATURE CUB'DIFFERENT) DATE: Fir 4,112frowe fat DIOS ilia dill 2 of 2 a , 14 millions einummit I ;g:il, - 1.. 0 2 1.1 01 - - P itirEts '8 ). gig 9*-91 1.1 1 I $ y�..v. a ›. 4 5 53i 1 .4 1 a m 0 ,2 "gy mg a 0 te ilg :4- % fI g� o r s -, m m o i;iiii H p ^. .: t,i ao 1E .3 .. i dsgo i Lit = r- g mil '�.= ° I . 111 -� u e i It i . 1Ei` 3 PF- 15" - agg 0 . 1— m , a In 5 illi o a �°'MId-al �''^' Ila a = 4'> 14 - ii 0! ung .: 1.1 qai 82ng *n * k 1 I al .0, a al oi5 . § x' i 'Gp .61 gg 1 ifilli � $ r A K is i- 7 A 4 C? Oc 0 jg la � G —1r �pf #1 �Sr so 1-111gi ' oil to 0 c Ig . =t --iii �f-c�i m m m_ 11 , II; , ill II 0 re 0 xi :�Yt pion `m u . 0 1 M 0 . 0 eigi o a A o gi 8 V a 2 m .M 5 ilic'-"c ,r• 0 c 0 o m §y ® m �"mSg{y� id K : 10- 51 gg% /D I Bli 1 o gt ve INUNg :s.a ii -71