HomeMy WebLinkAboutBldtr-20-004284 (1,,,Al.
'�o ' V VV lV OF I ARMOUTH i 7-iZ ZW�LZ• • :. `� e B ILDING DEPARTMENT Permi y 1146 Route 28, South Yarmouth. MA 0266 It Number ct :: ,:y. $08»398-223 I ext.126I FaX 08-398- Da
te ate Issued
Expiration Date
$50.00 '
Pursuant to G.L. c; 82 ,TRENCH PERMIT
A nand 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST RE FULLY COMPLETED PRIOR TO CON
Name of ApplicantSiD�7TON
ou,.. a„,,j er Phone
Street Address � � + Q Cell
ciaerown ZLp
. jal,VLt
Name of Disavow Of ditrer
c��uf1•om applicant) Phone
Street Add
ke � .t.1 l D�l. •Cell
�i %5 Wert f 1L e g q_8a7
�n MA. ZIP
Name of®one O�` (l� u1 j 11111111.111111111111.
Street Address �?Z�KJ •Phone •Ceq ,
..� Vs— //
3�T "J`�d ���/
City/TownhfA ZIP
Other Comm
o`er a dR ,6
Deacdpfotti)location and Perini Fee Received No Yea
Please describe the exact puiperBe of proposed trench:
Pfo location of the proposed trench and its
proposed trench(eg;pipeaicahk ii,�.etc..)Please use re kide itadd is
additions!Apace Bede is(or Is intended)to
b!laid in
wha
apace a receded
•
r
nsurnnce Certificate ItsDg
E C EI v E
Name and Contact Information of Insurer:
. Pup A' - . j
�/� I / 1 3UI ALONG bEPgR�1i
•
p•1•prati.on Dater. °
Did a N: u' 10P �J,
v ''460 .mod Y
Name of umpeteonl Person t • 7
rr ,, ned by SZte CMR y.(IZ)s
1 _ OO A
Massachusetts Hoisting License# HEogg5"gc
License Grade: 44 E. -,.-A 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 REGULATIONS,
G.L. c SM, 520 CMR 7.00 et 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 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 THE
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 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 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 WORK
CONDUCTED UNDER THIS PERMIT.
APPLI ANT SIGNATURE
W1//a-11
6/ (/6 M l�1-k- DATE
EXCA ATO jR�i/l.SIGN JURE(IF DIFFERENT)4,1_14/
1
6tL r / 1 ILU/ DATE ° 1`7-e) -
OWNER'S SIGNATURE(IF DIFFERENT)
DATE: / .7)
- APPROVED R Applkation Ice '—
Ft*titers,* . --Di►Ian write In Ws virtu
fr INOIT' `_'
mourn=AUTHORITY Ikatr
CONDMONS OF APPROVAL
2 of