HomeMy WebLinkAboutBldtr-20-003691 TOWN
��\@ 5�,�l dy ({�! �E( '"gip y�--g�
�`�;�R 19:0W-q17- C1/
('''(~F = \o BUILDING DEPART E Permit Number
�}� �ii 1146 Route 28 South Yarmouth, MA 02664
•\� -ATT:.t1+C EI 508-398-2231 ext. 261 Fax 508-398-0836 Date issued
Expiration Date
TRENCH PERMIT
Pursuant to G.L. c. 82A. §1 and 520 CMR 7.00 et seq.(as amended)
Tais PERMIT MUST BE FULLY COMPLFTED PRIOR TO CONSIDERATION
Name of Applicant &r 1_01v- ians-y-1 'V,., i-rx,c Phone Cell
Street Address IS" utj-'� -PJ- 6-0 S- yag- 2`.6.,
City/'Town MA ZIP
Name of Excavator(if different from applicant) Phone Cell
Street Address
City/Town WA ZIP
Name off Owner(s)of Property Phone Cell
[,Cum RAW)i A
Street Address t-1/ ailet _C_Or, Y/3- a/8' v ai
City/'Town �� MA ZIP
Lt.)• id tthivirteittrk 0a62 9 3
Other Contact Permit Fee Received No( ) ""Yes( )
Description,location and purpose of proposed trench: 3y ardibr, c.lt,ne - to' -.. ' ik
Please describe the exact location of the proposed trench and its purpose(include a description what is(or is intend .)to
be laid in proposed trench(eg; pipes/cable lines etc..)Please use reverse side eadditional space is needed.
`�c,w ti lv i'ci.,, �GX , 2- H to 67..o 0 i � �.r' et. a 5(,x/�.53'W
a 5 1"UL 6-1 ,c / C1on/e' / ex•'s,�i 7�00,y 0 ✓c v�-�
V°"Ad-taw e - y zt►.i, 4,(in ,ea (a1/4�•
G11 (033(.0
Insurance Certificate#:(gyp$C. 33
N es�and Con ct of rereation of Insurer:
/ty= r.Scvtq/bt� pz. ioX 3a�S ow ring, mAi S'S 06,0
is Es$,-33-3 - 1/,0.
Policy Expiration Date: 3 ')J ad
Dig Safe n: o2UR0 dta 8 3 i) S
Name of Competent Person(as defined by 520 CMR 7.02):
I of 2
Mas: _ausetts Hoisting License# /36 vo a /
y/y
License Grade: G-4- _Expiration Date:
BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWF.PDGE AND CERTIFY
TEAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF THE WORK, WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE'TO WORK PROPOSED;INCLUDINGOSEIN REGULATIONS,
G.L. c. 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 PO'
SUCH WORK WELL COMPLY THEREWITH IN ALL RESPECTS AND wrni 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 TE ' OWNER; AND ALSO, FOR THE
DURATION OF CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIIPALTTY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE
CONDITIONS ATTACHED HERETO AND TEII 'LAWS AND REGULATIONS GOVERING 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 CONNEC L LON WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW ARID CONDITIONS OF
THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES TAKEN ,:Y THE
MUNICIPALITY TO PROTECT tRiE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO
COMPLY THEREWITH INCLUDING POLICE DETAILS AND O 1 HER REMEDIAL MEASURES DEEMED
NECESSARY BY TEE MUN IC ALITY.
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 I UT
OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APPL IC GN
--DATE
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGNATURE(I 'DLFFERENT)
g"k9 '' I/ I — DALE: !(,�I4-U
=.. - - . Fur Cit`fro*t erg.-D d tllmi a &ad►aa ';
I RMIIT.APPROVED)EBY . • Biiea oa Fee
PERMTN ALITEIIO ' : • ED�o : • -
CONDITIONS Of A OV A II._..: • _ . •
2of2