HomeMy WebLinkAboutBldtr-20-004022 OF YARMOUT�I � LOT-Number
TOWN T berm
°` oy �+;. BUILDING DEPARTMENT
MA 02664
South Yarmouth, Date Issued _�_:
�// 1146 Route 28, 1261 Fax 508-398-�836
of . y 508-398-223 t ext. .. .s__
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TRENCH PERMIT ed)
cant to G.L.c.82A 51 and 520 CMR 7.00 et seq.(a amend
nd
�� D PRIOR TO CON
THIS PERMIT'MUST BE FULLY COMPLETE
SIDERATION
Name of Applicantioi,3e,c4.--r 1, 0 v `...0 .1.0 ' '
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Street Address \-If cp r.t..1,\
3 MA
City/row»
Neese of enter(if different Chp
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Street Address
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ril ) p I Po) i✓`• J Permit Fee Received No Yea
Other Contact �proper Leh: (Include a description d
Descri
what is(or i,intended)to
Please describe
locationbe the c and ocap°K ro trench and its purposeif a escr space is needed.
exact location of the proposed v,�side
Please d ri proposed the trench(e*;pipes/cable lines etc..)Ptesse use re x �f`a dI io sal(7 Ep ,i J ` "P���l
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/0i Sf i,cil SV &jay
Insurance Certitk*ls#I c ppi j-30
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•tin*Ind Contact(nftumstion of insurer. YJ�t� ��N PC) __-
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,Name of Competent Person les defined by 520 CJIA 7.02):
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License Grades Expiratioat Date: J jel
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,
GL e. 82A, 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, AUTHORI7FS 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 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 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.
APPLICANT SIGN' '
DATE / /ja`ao
EXCAVATOR SIGNATURE(IF DIFFERENT)
C ( 'AA DATE
OWNER'S SIGNATURE(IF DIFFERENT)
71, Retwx, DATE: I/ l 1Oa")
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