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HomeMy WebLinkAboutTR-20-4344 .,.... ' , TOWN OF V .�RN1Ot"TH 3 7�(473'144 BUILDING DEP.4RTIIENT Permit Number G7b` yy ,. is� ;, 1 ) 1146 Route 28, South Yarmouth. NIA 02664 'c' ` ` 508-398-2231 ext. 261 Fax 508-398-0836 Date Issued °buts. .` 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 COMPLETED PRIOR TO CONSIDERATION Name of Applicant ttis Are-fs cc �. Phone Cell Street Address ,.3 r h 1_, n;-se t 3( -. r d.3-7 City/Town IA ZIP f)e o WI Name of Excavator(if deferent from applicant) Phone Cell Street Address City/Town MA ZIP Name of Owners)of Property Phone Cell Street Address CJ k r -e4 14 (0 (7 - a 7 I LI 6 City/Town MA I ZIP we rr\QWh [ 0 2-a 7) Other Contact I_Permit Fee Received No( ) 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(eg:pipes/cable lines etc..)Please use reverse side if additional space is needed. ,�..., jtA -t Seri it- D E.-- V ‘ �T1G OEPATMEI� T 31.,i LD Insurance Certificate 0: i4, cc S -S C7(O 7 C 61 l- Name and Contact Information of Insurer: GC M l r /).'SiA --- el----` ---- Paticy Expiration Date: c, i Dig Safe0: 9,O?6 060 S ! L/ - 1 Name of Competent Person(as defined by 520 CMR 7.02): w r(la t I lk-S 1 of 2 F e • 45 Massachusetts Homing License F 11 E_ a I-- /z4C 4414- ✓- /a/3o J?G License Grade: 1-i 1 -ad k 073 _Expiration Date BY SIGNING THIS FORM,THE APPLICANT,OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT TREY 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. $7A, S20 CMR 7A0 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 ANND 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 Lamm)ED 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 v u,L¢ti , ) DATE � - S l.20 EXCAVATOR SIGNATURE( DIFFERENT) DATE Q 'S SIGNATURE(IF DIFFERENT) ,1,,,,,i4„. 6) ,ausize DATE: J._,,e 3 020020 ( --. .. - . . Far lib/rota we-Sir wet rrtM in*is seetli s= AP EDBY rk,�.�_M r. ..Fa- . PIlRanr NC AUTYIIarn Darr t f Comathore cw APPRIriAL . 2 of 1e } 1 Commonwealth of Massachusetts ti Dmsion of Protesswnalucensure . Ha L/'4iTrer r ires:.1213012020 . HE-028673 LAURENCE F-E 8 NORTH ST % 02638 , pENNISPORT MA , i;s��•.j i Commissioner Hoisting Engineer Restricted to: HE 2A-Excavators pl(,SAFE Call Center:(888)344-7233 In case of accident call: 508)820-1444 information about this license Cali(617)727f-3200 or visit wWw.mass'govidpi i�...,N REID&LA-01 DEATON ACORG," DATE(MMIDD/YYYY) 4.....----- CERTIFICATE OF LIABILITY INSURANCE 12/5/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of suc�hpe�npdorsement(s). PRODUCERrraayy NAME CT 4R3 RtBe 134'Inc. ",N,o,Ext):(800)553-1801 I(A,No►:(877)816-2156 South Dennis,MA 02660 Alm:mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:West American Insurance Company 44393 INSURED INSURER B:Arbella Protection Insurance Company,Inc. 41360 Reid&Laurence Ellis dba Ellis Brothers Construction INSURER C:Associated Employers Insurance Company 11104 23 Enterprise Rd,P.O.Box 59 INSURER D: Yarmouthport,MA 02675 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADOL SUER POLICY NUMBER IMPOLICY EFF POLICY EXP UNITS LTR. INSD MD MIDDNYYYI IMMIDONYYY) A X COMMERCIAL GENERAL LIABILnY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR BKW(20)58371201 3/1/2019 3/1/2020 pREMIS atEN0oirence) $ 100,000 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY 5ref LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ B AUTOMOBILE UABIUTY COMBINEDEaaaccident SINGLE LIMB $ — ANY AUTO — 1020002607 6/9/2019 6/9/2020 BODILY INJURY(Per person) $ 250,000 OWNEAAUTOS ONLY X AUTOS SCHEDULED BODILY INJURY(Per accident) $ 500'0� ��pyyryEp PROPERTY DAMAGE 100,000 X A URS ONLY X AUTOS ONLY (Per accident) $ $ — UMBRELLALIAO — OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION X STATUTE OTH- ER AND EMPLOYERS'LIABILITY Y/N WCC50050007062019A 1213/2019 12/3/2020 100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ (MFICER/MEMBEREXCLUDED? Y N/A E.L.DISEASE-EA EMPLOYEE $ 100,000 andatory in NH) If es,describe render 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101 Additional Remarks Schedule,may be attached B more apace IsCertificate holder is an additional insured under General Liability for on-going operations when required by=contract or agreement CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED /REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD