HomeMy WebLinkAboutTR-20-4685 =�� t_.�"40 BUILDING DEPARTMENT Permit Numa467' 20 5`4°FSJ
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' 'yg y 1146 Route 28,South Yarmouth, MA 02664
E'\»,►.;- 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
Expiration Date
$50.00
TRENCH PERMIT
Pursuant to G.L.c. 82A 11 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Nana of Applicant Rvtia t� tie htNtt( coitioctiky,RUL Phone Cell
Street Address V,a/ ck, 5' /5-110 20
Clty/Town f MA ZIP
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Naaee of Excavator(Watered from applicant) Phone Cell
Street Address
City/rows I MA ZIP
Newt of Ownerls)of Property ko es - Ph"/vb�0nei Cer
Street Address '`AT;a4g—
Clty!['own }f[� � L7 AM A k n
Ycrv4o t� I MA fo ZIP
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Other Contact 1 Permit Fee Received No l ) Yes( )
Dsseriplioar localise and purpose of proposed trend
Please describe the exact location of the proposed trench and its purpose(Inched.a deseripden of what is(or is intended)to
be laid in proposed trench(en;pipea/cable Roes etc..)Phrae use reverse Ado if additional space Is needed.
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Insurance Certificate h /
Nan,,and Contact Informs/ion at Insurer:
aghptre, i-u 5-01-p1 r(100
P.0c1 Espirattow Date: Ig/1010Dig Soh
I .Name of Cnmpetrnt Persoa as defined by SZm(Ml 7.e2 :
gteu clOt,‘_ ri I (ou rl'/Watfift)
6 91.-/, /3, ��
M+6■ech..etne Hoisting LksewI 11L-/VW/
Lietase G 2 A, 16 _ Expiration Date: 12/2042o20
BY SIGNING THIS FORM,THE APPLICANT, OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH,on,BEFORE COMMENCEMENT OF THE WORK,WILL BECOME FAMILIAR
WTTH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,
G LL. a SEA, US CMt 7.0II d sec, AND ANY APPLICABLE MUNICIPAL ORDINANCES BYLAWS 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 PERM T 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
RE>MMURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE
MUNICIPALITY IN CONNECTION WITH THIS PERMFF AND THE WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT LIMPED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF
THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE Tagatvirrni,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.
INDDEMNDY, AND HOLD HARMLESS THE MUMCIPALTTY 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 MJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROP WIY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APP r
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DATE 1-] '2OX)
CAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
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