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Home My WebLink AboutTR-22-4343pa 71v/zz Ot•YAR�i �O -in;�V� fCil TOWN OF YARMOUTH BUILDING DEPARTMENT 1146 Route 28. South Yarmouth. IA 02664 508-398-2231 est. 261 Fat 508-398-0836 Permit Number Date Issued Expiration Date TRENCH PERMIT Pursuant to C.L. c. 82A §1 and 520 CMR 7.00 et seq.(as THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO RECEIVED 042022 DEPARTMENT Name otApplicant 1`I Phone Street Address Cityfrown MA ZIP I Name of Excavator (if different from applicant) - Phone Cell Street Address Cityfrown MA I ZIP Name of Ownerts) of Property n `4-h yro Phone Cell So -77 fit StrTeeto�A red� /b t "S3 L-ei, S S Cfty/rown MA ZIP sI 1 oao73 Other Cbdtact I Permit Fee Received No 1 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 WQQdin proposed trench (eE: pipes/cable lion etc_) Please use revers We if additional space is needed. ' Insurance Certificate N: 'WI' CC $oo- S0000 e3 Co i Name and Contact Information of Insurer- 4 s e— Aee4 i'3 m Policy F.x iration Date: Dig Sate k: i tQ Name of Competent Person (as defined by 520 C NIR 7.02): u I of 2 Mae®dimdbHo&tinucen" tiE-e)aF673 /9 3p l a.oa.v Ikenn Grade. l 1 Elowim Darr BY SIGNING THIS FORM. THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT THEY ARE FAMILIAR WITH, OR, BEFORE COMINIENCEMEN T OF THE WORK. WILL BECOME FAMILIAR WITH, ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED, INCLUDING OSHA REGULATIONS, G.L. n 82A, 520 CMR 7A0 et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, RY-LAWS AND REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR SUCH WORK WH.L 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 REGUTATIONS COVERING SUCH WORK THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO REINIBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE MUNICIPALITY IN CONNECITON WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER, INCLUDING BUT NOT LIM[TFED TO ENFORCING THE REQUIREPAENTS OF STATE LAW AND CONDITIONS OF THIS PERMIT, INSPECTIONS MADE TO ASSURE CONIPLIANCE 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 DEFINED 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 TILLS PERMIT. =17 DATE EXCAVATOR SIGNATURE IIF D RENT) DATE DDI EREINT) DATE %y aZ �J202 2 of 2 i _ Cormmonvveakh of Massachusetts D"rvision of Professional Llcens�ne HgsBr+ �t?r r HE-028673 „�" ; a„ �Ores: 1213012022 LAURENCE � JR„�;. '" 8 NORTH S7�y (r _ DEWS pORTifAA 0 SS'1� Commissioner daA �+ 4 e � '.....*. - RHsffictedto; E -Excavator . Contact 0pW- 716Y 7 1: (� M144444 . . a200 orvwt `a*`sJftsL90WdPVo . i ACC>RL> CERTIFICATE OF LIABILITY INSURANCE DA y,*D ;�" 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. N SUBROGATION IS WANED, 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 such andomemerk(s). PRODUCER RogersGray, Inc. - Kingston Branch 63 Smith Lane - Kingston MA 02364 T NO'NTV PHONE FA T - 506-7463311 Nd, 877-816-2156 nooriss: mail ers re .com INSURERS AFFORDING COVERAGE NAICB INSURER A: West American Insurance Company 44393 INSURE' Reid & Laurence Ellis dba Ellis Brothers Construction-0 23 Enterprise Rd, P.O. Box 59 INSURERS: Arbel(a Protection Insurance Company,Inc. 41360 INSURER C: Associated Employers Insurance Company 11104 INsuRERo: Yarmouthport MA 02675 INSURER E: INSURERF: COVERAGES CERTIFICATE NUMBER: 2114965942 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 LTR TYPEOFpSURANCE DO POUCYNUMBER POLICY EFF Qff&VQYYYY1 POLICY EXP fMMODNYYYIUNISYS A X COMMERCIALGENERALuABILRY CINMSlAADE P�I OCCUR BKW58371201 3112021 31112022 EACH OCCURRENCE $1,000,000 PREMISES Ea occunerh:e $100,000 MED EXP (Arty mm perean) $15.000 PERSONAL&ADVILIURY $1,000,000 GENT AGGREGATE UMITAPPLIES PER %( POIJCY F-1JEC ElLOC OTHER: GENERAL AGGREGATE 42,000,D00 PRODUCTS-COMP/OPAGG $2,000.000 $ B AUTOYOBILELIABIUIY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED X NON-OWNEDSNLLY AUTOS ONLY AUTOS ONLY 1020002607 6/9t2021 6/9/2022 COMBINEDvil SINGLE UMIT (Es smide $ BODILY INJURY (Per pamdn) $250.000 IX BODILY INJURY Per estiderd) $500.000 PROPERTYDAMAGE ecdderR $100.000 s UMBREUALIAB EXCESS LUAB OCCUR CLAIMS -MADE Is EACH OCCURRENCE $ AGGREGATE s DELI I I RETENTION S C WORKERS COMPENSATION AND EMPLOYERS LIABILITY YIN ANYPROPRIETOWPARTNEWEXECUTNE OFFICERIMEMBEREXCLUDED? ❑ (Mandatory In NH) N yyeess desabeunder DESCRIPTION OF OPERATIONS belm NIA WCC-600-5000706-2021A 12/32021 1213=22 PEAT FO.R E.L. EACH ACCIDENT $100.000 E.L. DISEASE -EA EMPLOYEE $100,000 E.L. DISEASE -POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS LOCATIONS IVEHK;LES (ACORD101,AddMorul ReeTaras Sa uK, Manar lfmmespeeehraqulratl) Certificate holder is listed as additional insured under General Liability for ongoing operations when required by written contract or agreement Town of Yarmouth 1146 Route 28 South Yarmouth MA 02664 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. CORPORATION- All rimhts reserved_ ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD