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'�'� 11t� TOWN OF l'ARNIOLITH
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� �eI-Ixlit amber r �
y's; VI t, \p BUILDING DEPARTMENT
gli " 1146 Route 28 South Yarmouth, MA 02664
�,`c` -. : � 508-398-2231 ext. 261 Fax 508-398-0836 Date Issued
J E.
Expiration Date
TRENCH PERMIT
Pursuant to G.L. c. 82A. §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COI F->NTED PRIOR TO CONSIDERATION
Name of Applicant 80r1,,vi o- ConSi.,C(...)dcpe. ;IOC Phone Cell
Street Address y 5�1—rY4 c t>a 5'USS- a 8-$cj a Co
City/Town MA ZIP
040,0 ) i\k ) O L
Nance of Excavator(if different from applicant) Phone Cell
Street Address
City/Town MA " ZIP '
Name of Owner(s)of Property Phone y� Cell
9114
Street Address 3S— c ,2A- ,
City/Town -MA ZIP
P . tIA4U AiJ , �5i,9
Other Contact Permit Fee eceived No( ) Yes( )
Description,location and purpose of proposed trench: I I Mai f C Ave, to.cknAriotktA diekYoti 6249/4-
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(eg; pipes/cable lines etc..)Please use reverse side if additional space is needed.
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Insurance Certificate#: le(-"Cf a33 c^
bcge,g•-36, `A
Name and Contact Information of Insurer: w 54SS- ,33'- -q 977
t M (jx0 az2..b,1 tick_ 1 M N 5S bC CU
Policy Expiration Date: 3107 1-)
Dig Safe#: &Ua0 osSG 3c!gel)
N me of Competent Person(as defined by 520 CMR 7.02):
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Mast _eAusetts Hoisting License# '✓���ot�
/ay/A
License Grade: g-P Expiration Date:
BY SIGNING THIS FORM, THE APPLICANT, OWNER, AN' EXCAVATOR ALL ACKNOWT.FDGE 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. S2A, 520 CMR 7.00 et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, ,,Y-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.
TEE 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, AUTHORI7 --S PERSONS DULY APPOINTER- 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 4 Y THE
MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDE ,
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 0 EXCAVATOR HAS FAILED TO
COMPLY THEREWITH INCLUDING POLICE IIETAILS AND OTHER REMEDIAL MEASURES DEEMED
NECESSARY BY THE MUNIC;r'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 EMPLOYF FS F"'OM
ANY AND ALL LIABILITY, CAUSES OR ACTION, COSTS, AND EXPENSES RESULTING FROM OR ARISING OUT
OF ANY INJURY, l EATH, LOSS, OR DAMAGE TO ANY PERSON OR P!'OPE;'TY DURING THE WO r'K
CON,r UCI.D UNDER THIS PERMIT.
APPLICANT SI URE
DA
E CAVATOR SIGNATURE(IF DIFFERENT)
DATE a I j -C)
ER'S SIGN RE (IF DIFFERENT)
�ifll /' i��� DA FE: I"t I c1
. - . Ft*City/TO use.—Do oa►t write iioi pfionfi'i;eetie►im;...,
PERMIT APPROVED .;
PEfl A1Frmi AUTEHORITY•.. . . ' . •: DAC' - • -
CONDITIONS.Of APPROVAL.... • • ._
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