HomeMy WebLinkAboutTR-20-4126 v. ,loses - cm) •
TOWN OF YARMOUTH
r {- 4 BUILDING DEPARTMENT Permit Number
( ,, r.yg y 1146 Route 28,South Yarmouth,MA 02664
- .y r 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
Expiation Date
gc br z- -4 $50.00�
TRENCH PERMIT
Pursuant to C.L.c. 82A §1 and 520 CMR 7,00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Named Applicant Cali p2 7 Q I n(� ins Cod
Street S Addrem
f/r 7 n cp S`3 ) O 041.47)I S3 u U l
c /rowsZIP
SO h'1b MA braLtU/
Name ofxcsrator(if different from appdcant) Phone Cell
Street Address
Citylrown MA I ZIP
Name of Ownsres)of Phone Cell
sateAcidtioCcvlic1 114010 !IT
Ck !Town I MA I ZIP
- yMaIr - 0 aU73Other ntact
j Permit Fee Received No O Yes t )
Dsuripdon,loads.and purpose of proposed trench:
Please describe the exact location of the proposed trench sad its purpose finch.de a description of whit is for is intended)to
be laid he proposed trench tea:pipedcebble lines etc.)Please me reverse dde If additional space I.needed,
20C r paJ(1 PO)Va LJi' o f Prbligay
RECEIVE ' 1
JAN 28 202C
routines Certificate tin J
By
Name and Contact Information of Insurer
y` Ins.
Pr Ft don Date: p ---
Dim w dhab * d �� a
Nam of Competent Permit!as defined by 520 CMS 7.I2):
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Maireehasetts Heisting License. L /a31 5 J
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License Grades ► ) ar 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 WORE,WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED.INCLUDING OSHA REGULATIONS,
G.L. a BA. 52S CMS 7.00 et sec,,, AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND
REGULATIONS AND THEY COVENANT AND AGREE THAT AU.WORK DONE UNDER THB PERMIT ISSUED l�OS
SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH
BEL.OR
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OR THE OWNER, AND ALSO, FOR THE
DURATION OF corentyCFION, AI THORECES PIMPS DULY AFvaNIlD BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND zwricer THE WORT FOR CONFORMITY WITH THE
CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH WORK.
THE UNDERSIGNED APPLICANT.OWNER AND EXCAVATOR AGUE JOINTLY AND SEVERALLY TO
REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND VIPENSES INCURRED BY THE
MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING BUT NUT LIMITED TO ENFORCING 11W REQUIREMENTS OW STATE LAW AND CONDITIONS OF
THIS PERMIT.INSPECTIONS MADE TO ASSURE COMPLIANCE TAP E irru,AND MEASURES TAKEN BY THE
MUNQCIPAL ITY To PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO
COMPLY TIIRREWITTI 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 BOLA HARMLESS THE MUNICIPALITY AND AIL OF ITS AGENTS AND EMPLOYEES FROM
ANY AND ALL LIABILITY,CAUSES OR ACTION,COSTS►AND EXPENSES RESULTING FROM OR ARISING Our
OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
CAN'T SIGNATURE
DATE //a-1a
EXCAVATOR SIGNATURE OF DIFFERENT)
DATE
OW E 'S SIGN RE( RENT)
TE: 07' 27)
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