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HomeMy WebLinkAboutbldtr-20-004090 aa -tea - 00g09 bg•v TOWN OF VARNIOI'TH v fee t �a BUILDING DEPARTMENT Permit Number o. 4R d✓E 1146 Route 28. South Yarmouth. MA 02664 + ,- Date Issued �.. ��y_' 508-398-2231 ext. 261 Far 508-398-0836 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 +I ls ( rop 6 6,4)- PhODe Cell Street Address �& 3 2 d 6 3 a3 ► h�ren� ) City/town MA t ZIP ( 4 r hleArr I G96)5 Name otExcavator(if different from applicant) Phone Cell Street Address City/Town I MA I ZIP I Name of Owner(s)of Property yeti It lyre tzpv5 Phone Cell Street Address( / iI jS�') f SQ p3.S )c9 ,39 City/Town MA I ZIP C-C,i7-11 ygrines. I 0 c)-&-(0'I 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"tresnch(eg;pipds lcable lines etc..)Please use reverse side if Additional space is needed. VI -eq.. Seel-=e M ri S' q I r CEIVEr,°7 AN DING DEPARTMENT-- Insurance Certificate if: W 66 SC3c S coo 7 G G av Name and Contact Information of Insurer: i....61, Policy Expiration Date: 1/35 II 6 Dig Soft te: 9.0a0 0 3 0 ?03(0 Name of Competent Person ias defined by 520 CMR 7.02): i QqI ` 1I$ 1of2 45 Massodnsetts Raiding License License Grader. 14-'1E—O'f t _Expiration Date: 1 cg 1,-3()/a' BY SIGNING THIS FORM,THE 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 AM)REGULATIONS APPLICABLE TO WORK PROPOSED,INCUUDING OSHA REGULATIONS, G.L. e. BRA, 520 CMR 7.0 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 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 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 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. APPL CANT SIG TORE DATE l!�"'26 411 EXCAVATOR SIGNATURE(IF % ' ' ' �+ DATE OWNER'S SIGNATURE(IF DIFFERENT) Linetra, .7).02344. DATE: l//�J/0-O " Far Cits/Tens ewe—®i►list write is tMi se___ fPl�i11rT APPRO%is ii' f:_ � APi a ie.roe PIERMITTING AL Mop CONIMONS MAMMAL AMO%AI. [ _ - _ • 2of2 Commonwealth of Massachusetts DNi�on of Protesstona'LUcensure i� Ho iiiji+rer ayires:1y3012020 3 �} HE-02867 = ,i i ' r - LAURENCE F-ELUS `'«£ ` 8 NORTH SIT MA 02639 ti , pENNISPOR f p: •I ..-' l/' Commissioner Hoisting Engtneer Restricted to: HE 2A-Excavators DIG SAFE Call Center(888)344-7233 call: 508)820-1444 In case of accident�this license For information ss,govldpl Call(617)727-3200 or visit vrWW -.14,1 REID&LA-01 DEATON A�oRo CERTIFICATE OF LIABILITY INSURANCE �12/5/201TE 9 n 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�hpeeTndorsement(s). NAMEA PRODUCER CT 434 Rtree 134'Inc. PHONE Ehd):(800)553-1801 FAx c,N0):(877)816-2156 South Dennis,MA 02660 �,mail@rogersgray.com INSURERS)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 ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER SAWDONyyyl (MM(DD/yyyy) UIUTS A X COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR BKW(20)58371201 3/1/2019 3/1/2020 PR MISEs(�F.RaE"o urence) $ 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 Tel, J LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ B AUTO OEILE LIABILITY (Ea aBItSINGLE LIMB $ ANY AUTO 1020002607 6/9/2019 6/9/2020 BODILY INJURY(Per person) $ 250,000 — OWNED ONLY X AUUTNOSyUyLNE�D BODILY INJURY(Per accident) $ 500,000 X AUTOS ONLY X ARl ONLDY (Per tDAMAGE $ 100,000 $ _ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION X STATUTE OT AND EMPLOYERS'LIABILITYER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/" WCC50050007062019A 12I3/2018 12I3/2020 E.L.EACH ACCIDENT $ R 100,000 ZIICdEInM Y EXCLUDED? N I A MM °""y E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101 Addia�l RemarksIS.dhedule,may be attached if qu space is Ued by required)__ g Certificate holder is an additional insured under General L_Additional abil for on-going operations when yrritten contract or agreement. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE I ( :)./70;:Figi 7 ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 4