HomeMy WebLinkAboutBLDTR-20-003724 TOWN OF YARMOUT ,� Permit N
uref 72
`` of'YA't4 BUILDING DEPARTMENT
RM 02664
ate Issued
.�' 1146 Route 28,South Yarmouth,Fax A D
of 5f18-398-2231 ext. 1. F,V—:—^,t;yYi rt
ps $50.00
TRENCH PERMIT Pursuantamended)
THIS
to G.L.c.82A $1 and 520 CMR 7.00 et seq.(a
15 PERMIT MUST BE FULLY COMPLETED PRIOR TO CON
SON
�.[' Phone
Cell
Nome of APPtiant !Ol c� ` CV °�. CO , M n* �I.Sj� 6J«�
t�
Street Addr�e . n► C t' 1�
MA ZIP
City/ own�� A.
1 V I\Ar C):1.`{ � Celt
1111111111111111111111111
Name of Excavator,lid d;tfert:rt frogs nPPkrone)
NA_ L0r1-‘ . iiiiiiiiiiir �� -' l� �l
Street address �c l�k) c W.., C i. C t..t
A ZIP
City/Town tA r. O 3-. Cellptwne
Nan* Ow t of Propel Li i r. et0 Ds
Street AddressQ{'
j , tU 6110'0 . i ` Nr1 ZIP
NIA:Q;��� �C1 �'1 p�r�t Fee Received No Yes
IIIIIIIIIIIIIIIIIII
th d what k f or is intended)to
DeOther scription,location and purpose of protactd tre+chret+�and its purpose(include a descriptionis needed-
plesse describe the exact location of the proposedside if additional space
(pQet/cabk Hoes etc-)Please use revue' J � L
41
3� Q.A 1
Insurance certiticats Its
Vane sod Cootiet tnformstion of insurer:Ro .T 0"T..Q.0 Nci-iiiiii " -A4Aiiiii
Po IN. ration pate: -
l
Dig Safe M: A 0 • i� tI
AiIIMIrMAIMI
Same of Competent Person Ian fi ned by 520(III/02).
I. of 2
f .
Nizw= :t Its H oLgting Lketwe# ,-tc-- I Odk.3
•
oN
License Grades Expiration Date: J` r`t
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 e. *ZA, 520 CMR 7.0111 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 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 AM)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 /! c3/020
EXCAVATOR SIGNATURE(IF DIFFERENT)
\a%:0&j . DATE \\§\113
OWNER'S SIGNATURE(IF DIFFERENT)1; +
APAti� Ker 6 DATE: t C
Fat lir{t' r. or wit wrift it
riciiibrnwiAtrivent
Dor
Ifs '
mairilOpifforAnaottik
2of2