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HomeMy WebLinkAboutBldtr-20-004023 „r , (18Fi'diR,,pTOWN OF YARMOUTH ,yq C BUILDING DEPARTIIENT Permit Nu&"7`'e — LAD •��a3 _ '►, y 11.16 Route 28. South Yarmouth. NIA 02664 tt."^ - w'y m08-398-2231 ext.1261 Fax 5(18-398-1)836 Date Issued 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 Applicant lid-et. &Rd A lercict.I.LJ PhOOe Cell Street Address 'Sg e ”`�-,I t ,50 U .5 0)�-1--/�}I d k uw1' i : ri City/Town MA ZIP , tk,vu5 1 o -c0 3 9 1 Name of E vator(ifdifferM from applicant) Phone Cell Ut. f „ eauiIQ�t, / c., / r� Street Add SUS, ' 1i 1 2"Jo` ,51 --4.--flbrt vtio L-GtAi- Cit�W�Fpwn MA ZIP — Name of Owners)of Property aifQy�_ ,p Phone Cell / Street Address -6, Or , ....4 x _ cF'-'-c36 v_a v_c, f Cky/Town MA ZIP gr, e?-3. Other Contact I Permit Fee Received No( ) Yes( ) Descriptio14 location and purpose of proposed trench: / / r Please describe the exact location of the proposed trench�nd its purpo (include a descript10 dl' ( nt to be laid in proposed trench(eg;pipes/cable lines etc..)Please use reverse side if additional space is needed. 511-4 1,/t/CL&e,0 Insurance Certificate tt: I► 1 pi n n n.. 01\.01 9 IName and Contact Information of Insurer: i 0-0 'P,15 c LI jrnuAarivrr.e- .U0 -3�1 • 79I 7 Policy FYpiration Date: `h I go)9 '�_ Dig Sate M: ©Li° ...c)-rr -i 0 Name of ompeteptt Person m :tied by 520(MR 7.02): JAI/U-141 1 4,L 1 of 2 • } • I. s Massachusetts Hoisting License 0 H Eo gg,7 g c 1/�-1 I o/�J „�11 License Grade: }}E. _, .A Expiration Date: -ld-v 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. e. 87A, S20 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, AUTHORI7,FS 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 CONDmONS 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 OP ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT. APPLI '- ANT SIGNATURE ilk)-4 �� DATE EX�CA ATOR SIGN�' RE(IF DIFFERENT) ki,,, '( �r !Luc,' Lu DATE OWNER'S SIGNA (IF DIFFERENT) q DATE: '- i - ' 42,0 For('ftb/Towa we--De tint write in this withal'PERM T AP'PRI)W'IE R BY ! Application Fee PERMriniu;a rillDate I CO 4D[I im;or AkRovas. • g . 2of2 i