HomeMy WebLinkAboutBldtr-20-005041 TOWN OF YARMOUTH P
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..., 4:.-6 -.. BUILDING DEPARTMENT Permit Number
- g( i4?-c; 1146 Route 28,South Yarmouth, MA 02664
508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
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Expiration Date
$50.00
TRENCH PERMIT
Pursuant to G.L.c. 82A 11 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name et Applicant Cape 1 inc_ _ Phone Ced
Street
AdIT SO Yr100(42) TWAIV/01
City/Town MA ZIP
S. \frttIMK _ Oa(Ko-ii
Name of Excavator tit different trots appertain) Phone Ced
Street Address
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City/Town MA I ZIP
Plaint 411ZIV7 Pgrieff //I/6S*/- Phone Cell
Street
v,r--i igAihie Lo 11.419\( L.030
City/fawn MA ZIP
OthuiPntact IM
I Permit Pne Received No( I Yes( )
Deseriptioa,location and purpose of proposed trench:
Please describe the exact location of the proposed trench and its purpose(include a deseripdso at what is(or is in(ended)to
be laid in proposed trench(eo pipes Komi ear..)Please use reverse side if addltiorad space is needed.
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insurance Certificate lb Li zz 0/02 414v3Q(-6--- ,6 iq
Name sad Contort intortnatioo if insurer:
Gt (il _itliricam)
Palky Expiration Date: c, - -
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gndide;ftellib
Name ' Xt1200
of Competent Perim I ss by 520 CM*7.11I3:
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_ Expiration Date
BY SIGNING THIS FORM,THE APPLICANT,OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH,OR,BEFORE'COMMENOIMENT OF THE WORE,WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATE APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,
G.L. e. $2A. SDI CMI US d seq., AND ANY APPIiCABLE MUNICIPAL ORDINANCES,„BY-LAWS AND
REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERM??ISSUED FOR
SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTE
BELOW.
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCK WORE ON THE PROP=TY OF THE OWNER, AND ALSO, FOR THE
DURATION OF CONSTRUCTION, AUTO PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR APO INSPECT THE WORK FOR CONFORMITY WITH THE
CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH WORE.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
RICIMINJESE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE
MUNICIPALITY IN CONNECTION WITH T IE'S PERMrT Alai THE WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT UNTIED TO ENS ORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF
THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWYTH,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 AM)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.
APPLIC T SIGNATURE
DATE 3II2/;"6)
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIC/,IATU ( DIFFERENT) �J �c�
ATE; 3 ! Eae,U
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