HomeMy WebLinkAboutbldtr-20-004707 OF YARMOUTH Permit Numbe t, � D 7
• TOWN
,,: �_
`` ovYAR BUILDING DEPARTMENT 664 ate Issued
1146 Route 28,South Yarmouth, D
2231 ext. 1261 Fax 508-398-0836 _
of - y 508-398- IP--- -- -ry_ °":;.�.
t�,�..f. $50.00
TRENCH PERMIT
as
uan P ,�n MUST BE FULLY COMPLETED to G.L.c.82A it and 520 CMR 7.00 et seq. amended)
CONSIDERATION
vas
�� Y PRIOR TO CON
Ceti
PhoneName at Appiiront Rob.oc-i- Q• Ova. So?)y3 -bS�o
Street Address_A3 w�,�s Pr.,�'k '�
MA VMIIIINIIIIIIIIIIIIIIIIIIIIMI
City/Town rnA. CeU
Y4cnn°J}h Phone Name of Excavator(if different from applicant) �3b_ � �
�c,� S o�Z
Street Address to {- kai sn 04 `MA
1111111111111111111111111111111
Ci.QA1-tyff own 4 1}- D d6�a ceCellC�2/��� ZIP
taQ, Pho"c
Name of Ownertsl of Propel
Street Address
City/Cown
ldlidIIIIIIIIIIINIIIIIIIIIIII
Permit Fee Received No Yes
hs description d what is(or intended)to
Contsu't treat (seclude■desc p
Other
describe
be the exact
and purpose of the proposed trench and its purpose is needed.
)ovation of proposed side if additional space
Please in rox the trench(es;pip�/nbk lines etc..)Please use reverse be laid in proposed
gNhe eZ- W . l6%r►A-- FZEC VEp
fM < G: Apr_.
r41�1 �rvC� WIC ti e i 1 1 tii/1 1361c-, \t -•
5
Insurance Certificate IllCQ i 3b %An
Name and Contact information of Insurer: _ -
• Pa Ex.iration Date:
' Dig Safe0: ao9.0n1 0LiII 1
Man*of Competent Person las defined by 520 OM 7A2):
30,50r‘ A 60vZ
1 of 2
•
•
Ibliastsette Heisting Lim it N E— 719) ?Cgi
• 1$SIo3
•
License Grades 14&.-- 1(, t� 14 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
WTTIL,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,
G.L. c. $2A, 5211 CMR 7.N 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 HARMIXSS 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.
APPLIC T SIGNATURE
DATE 2,S ) 2 0
CAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
For t1bITowat inn-O►e not wMMs i!tie
=114111801011*M14
corimbilioirAnotottiE f '
2 of 2 i