HomeMy WebLinkAboutbldtr-20-005044 _ 4 TOWN O ARIV O U'i
�;7 QY�`P` D DEPARTMENT Permit Numbt 0 'a� 'Ud.4f
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Uj0E 1146 Rout'' 2S.Sox i��'ari_�_ouuth.MA.02664
��, - 508 98 22 1 et. p - 08 Date Issued
rf\M?.-TA esa: n "J U^ J 1261Fax� z^—' a.^1:c9�t9
�� �y 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 CONSIDERATION
Name of Applicardri9 atliAdeic
Phone Cell
Street AdAirs a✓v.5.�
gt. i /w, Email Address:
City/Town MA ZIP
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Calf )'; v V zi�,j 3
Name of Excavatopillifferent from applicant) Phone Cell
Street Address V141"---
Emaail Address:
City/Town MA ZIP
Name of Ownerts)of Property C1A, /O . F. �7v ; Ari 4Phorw Cell
Street Address
4g Rig el - ,O', y G." -44c. Email Address:
City/rown :ETA ZIP
Other Contact I Permit Fee Received No( 1 Yes( 1
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(e.g; pipesfcable lines etc..)Please use reverse side if additional space is needed.
0d14,/.',7 4 iuerec.) 1t.1 L 5'.* gar-C r'^-
Insurance Certificate#:
Na and Contact Information of!usurer:
�I�0 414— 2-4_5,
Policy Expiration Date: Y'' I
1
Dig Safe#:tc /is L p 3 7 I_ ! ° h 10
Name of Competent Person(as defined by 520 CMR 7.02): W. P Cl
5. 601 -- 6mievivy# . ., ,,. „,„,.. ,,_,_,,,,:,_, _.
1 of
.f
!Fame of Competent Person(as defined by 520 CMR 7.02):
„3-40.,--a.„644
Massachusetts Hoisting License# 574Z-0/
License Grade: Expiration Date:
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 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
CONNDITIONS 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 FAIT ED 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,
I_NDEMNIFY, AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM
ANY AND ALL LIABIITY, 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.
APP IC T SIGNATURE /
' L — DATE Sfr- �
EXCAVATOR SIGNATURE (IF DIFFERENT) ///
DATE
OWNER'S SIGNATURE (IF DIFFERENT)
DATE:
:For City/Town:Use,--...-Do not: +rite=in this:section-
PERMITTPROVEI3-BY $ -= APPhcation Fee- -
-_PERMITTING=AUTHORITY - _ - IIate` _ -