HomeMy WebLinkAboutBldtr-20-003623 TOWN OF YARMOUTH
= Roo BUILDING DEPARTMENT Permit Number 7,2-2o--a 23
�ff �. g C 1146 Route 28,South Yarmouth, MA 02664
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ti&.. ! . 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
Name of Applicant 110AM l� v Pliona CrN
8' I17N(1R)/V j uz*to 713 43
C&y/Town MA ZIP /
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Name of Excavator lif different frown a pplicant Phone Cell
Street Address
City/Town MA ZIP
Name of Owneres)of Property . Phone Ceti
tAare.: I iZ-7,I
619-Ve1tE D/ -�1q gq'a09
Cty/tome MA ZIP
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Other Contact I Permit Fee Received Not 1 Yes t
Description.location and purpose of proposed trench:
Please describe the exact location of the proposed trench sad its purpose(Include a descrtptioa of what is(or is intended)Os
be laid in proposed trench le=:pipeafcable Noes etc.)Please use reverse dde if additional space Is needed.
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Insurance Certificates:
Name end Contact information of Insurer-
pcuticeAl ZOYic 1n5,
Policy P_spirstioa Dante: ( • O
Di8 eare fti dbl 520 3�3
Name of Competent Pens!tan defined by 520(AIR 7.82):
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' Ikense Grade: I L) ap- _Expired=Dates a -az)
BY SIGNING THIS FORM, THE APPLICANT, OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WYTII,OR,BEFORE COMMENCEMENT OF THE WORK,WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS.
G.L e. MBA, 511 CMR 7.410 d sec, AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND
RSGLIATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR
SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITS THE CONDITIONS SET FORTH
BELOW.
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY TOR 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 PBRMTT 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 Ti straw H,AND MEASURES TAKEN BY THE
MUNICIPALITY TO intoner 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,
I'llD1331NDY, 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
OP ANY INJURY, DEATH, LOSS,, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMfl:
APPLICANT SIGNATURE
DATE
EXCAVATOR SIGNATURE(IF DIFFERENT) �J
DATE t z/Z I /
OWNER'S SIGNATURE(IF DIFFERENT)
--•____ DATE: /2 J 1 ( 1
. tit aliNive SO 4.11 iL_____ihlrillablrnitatrra
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