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HomeMy WebLinkAboutBldtr-20-003513 TOWN OF YARMOUTH Ao -0e3S/3 YAR4o BUILDING DEPARTMENT Permit Number C 1146 Route 28,South Yarmouth,MA 02664 Date Issued :� MArrA m � 508-398-2231 ext.1261 Fax 508-398-0836 • EJ' Expiration Date $50.00 TRENCH PERMIT Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO Oath '.a��� S CONSIDERATION � Name of Applicant Phone Cell 7? �16-5 �Street Address 30 Oltaced-rCltit g Email Address: C ' 1 5 3MaSk,Cc>tit Citylfown MA ZIP vta/kiNC,Name of Excavator(if different from applicant) Phone Cell Street Address SAV""e Email Address: City/Town I MA ZIP Name of Owners)of Property -cz prk0 O Phone CeU Street Address 21 1v1Deviete rt .set& `��`2- is 3 Email Address: CitylTowrr MA ZIP qv:\rutoo- I Other Contact I_Permit Fee Received No( 1 Yes( Description,location and purpose of proposed trench: Please describe the exact location of the proposed trench and its purpose(include a description of what is(or is intended)to be laid in proposed trench(es;pipeskabk lines etc..)Please use reverse side if additional space is needed. new S`ep t c t6' cA4-e t,,,t der S ery t oc l4dS Insurance Certificate N: 5 G7[r q r 3 8 l/ l ` Name and Contact Information of Insurer: Li Policy lEapiration Date: Did Sate f: 2.0 F '3 Name of Competent Person las defined by 520 CMR 7.02): 3ô\t' ti o ram► y ' Name of Competent Person(as defined by 520 CMR 7.02): c OVNA Massachusetts Hoisting License# I) 5 / 2O 7 License Grade: I A' 12 A Expiration Date: (O / 2 / BY SIGNING THIS FORM, l'HE 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. 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 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 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 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 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. APPLICANT SIGNATURE j © � i ' tt" DATE 12- I E' " AVATOR SIGNATURE(IF DIFFERENT) DATE OWNER'S SIGNATURE (IF DIFFERENT) di DATE: I2 / 7 Yr-a -vx' f: z`� .,F