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HomeMy WebLinkAboutBLDTR-23-003321 mCLI 1e( illy/ ' (Si Yap TOWN OF l RNIOl"TH ' !`'o :ABUILDING DEP.%RTNIENT Permit Number 01 772-a5- e` 1146 Route 28. South Yarmouth. NIA 02664 1�3,y r 508-398-2231 ext. 261 Fax 508-398-0836 Date Issued a�33a1 Expiration Date cO.OT) r a813 RECEIVED TRENCH PERMIT OEC 14 2022 Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended) 3.jjILDING DEPARTMENT THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATI Phone Cell Name of Applicant --- �r f C : i rS f-0 IjS� Stet- 3G CO3 Street Address 1z 1- e/ City/fown J(Afrh 41or Ill P'' 7S Name of Excavator(if different from applicant) Phone Cell Street Address City/fown MA ZIP Name of Owneris)of Property Phone Cell Street Address c5 o e�-a 3 7 1 ,1-'7 ���0 FORt5s7 f20 ,1) City/Town MA I ZIP t , eS f N a I PI yh dc;)-62 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 trench(eg;pipes/cable lines etc..)Please use reverse side if additional space is needed. Seri, C ei, C c:,yS1.4 Insurance Certificate 0: L C/C-So0 Name and Contact Information of Insurer: it)S SG cMiNkcil ovel_ Policy Expiration Date: IA 3(3.3 Dig Sate: fl o a2 sod Name of Competent Person tas defined by 520 CMR 7.02): 1of2 ... „ • . , - , .. ,,,. • -11 , ,-,.., .t -:' f I(.)4,-' 4 / / vi . ,. ...,4,.V.r*".'';;*-, \‘' ''t 7.,- :. k,. .- .• ) • .,,e-4,.4, 4,-;e ,4 ;', Q ..;';*St.•'•;.' . ''''''... I 4 ;-.k'• : 'f-••"' %'.11:-, 4414041$ 44 -, .:4!#.-,4411.4.4. •;--7'.:t•;',;41.414?", 7•ii7(.1 vir •,.... .47.4k- '',0'' 1 ,:;!' ', 'c •7 : ,.. '" *•'''',1 V ..ftef ::4 ''' • ;,..stk-us 1.-.•,.'.rld, .,,,,,,,41 , - . r• 'ililt re', "le•Ilr A -,'. . .... ... . . . 1 :k.,:$ - n.• 1 - . 1 '; :TIlli,...;f. -Ft•ti.;.0-;-;',... , ss, •-;„-:;r.' 1:;#A.;',-; „I. f,",;„' 1:7674...; ,T, ,.#.,.....`: .-•J ...:.i'„i.'"). 44. IA-4';'41.,,,-'74 A.I9 , Ascii / - i , !,.::4 :, .,,,, ii ,7.1 7. , , . 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AT...0,4,ralt )1,, ;,: iii•e, . 1 . ' .._ __ . „ _ . . • . - , . . . . — __ I IMassachusetts Hoisoug License# Fir IE.`-cga8 4 3 I ' 30 a da Pt License Grade 14 t -a& 'J iw,, ✓ 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.% 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 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 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 OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT. APPLICANT NATURE - CT,O `r , -3 - .3� EXCAVATOR SIGNATURE( DIFFERENT) DATE 0107ER7S SIGNATURE(IF DIFFERENT) -- '>e ✓f S)Ita4, ' 'Lai DATE: 7 -23—2`Z L. / FIR Chill own WV-••Ili not 1il rite in Minicabs' PFILMiT.1MPRO%EDB1 _ — _ sy.-'_A reFte PERNIM ING.1 ti HORITI th/� , ] C COYDTTIo%s uF:1I'PRO%AI. . • 2 of ; i • •••• ..„ „ . . •; • ;•_ ..4;0IgrAY"' :•• =•:••' -••• • • • " • • •:.•1 • • • # •r /4-4 "5-T 3t, 4 ••'-;, • •- ?.f) ; r !• 7 • •'; • 7,0 .,';;"4".11.4*}1.•ez.' , • A1 . .Li:- 7••• "• ;""° • • • 7 ' '•• •7,7:47.'; 74? r e , ' ibt'd• IAA r-• • ' • ""';•'-• 7"-•;""- • • - -, • TT-f %;-) ..X.`,4,";-• ; • • 1: ••• )13;F:r=rsr I_P`•".4;f-' (.4 3' ' ' : •••• • , -Aterromivorr4.1.1rip-1.7rvaKA'717;,e--.) 11:yrflit.hvtrfiffopy,.. • _ • ., , 7 - • • ; • 1- •f "••••• . _ • • , - : • • . „_ ...„. • •- • Commonwealth of Massachusetts Division of Occupational Licensure Hut3`tn4W iiwer HE-028673 Spires:12/30/2024 u LAURENCE ELLIS JR. , 8 NORTH ST. DENNIS PORt MA 02639 Commissioner Cladga i. Yera Hoistin5,Engineer Restricted to: HE-2A-Excavators DIG SAFE Call Ce:-der:(888)344-7233 In case of accident call: (508)820-1444 Contact OPSI:(617)727-3200 or visit www.mass.govldpllopsi l ®ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MIN/DD/VYYY) 11/16/2022 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(Iss)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 such endorsement(s). PRODUCER CONTACT NAME: RogersGray, Inc. -Kingston Branch PHONE 50&746-3311 cFAl�c,Ne1:877-816-2156 63 Smith Lane (AIc.NO.Ext): Kingston MA 02364 nDRess: mail cv rogersgray.com INSURER(S)AFFORDING COVERAGE MACS INSURER A:Associated Employers Insurance 11104 INSURED REID&LA-01 INSURER B:West American Insurance Co 44393 Reid&Laurence Ellis dba Ellis Brothers Construction 23 Enterprise Rd, P.O. Box 59 INSURER c:Arbella Protection 41360 Yarmouthport MA 02675 INSURER D: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:2021067994 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 POUCY EFF POLICY EXP LTR TYPE OF INSURANCEINSD WYD ADDL SUER POLICY NUMBER IMM/DD/YYYY) IMNVDOIIYYYY) UNITS B X COMMERCIAL GENERAL LIABILITY BKW58371201 3/1/2022 3/1/2023 EACH OCCURRENCE $1,000,000 E TO CLAIMS-MADE X OCCUR PRA MISES(EaENTED occurrence) $100,000 MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GEM.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY ECT- LOC PRODUCTS-COMP/OP AGO $2,000,000 S OTHER: C AUTOMOBILE LIABILITY 1020002607 6/9/2022 6/9/2023 COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $250,000 OWNED X SCHEDULED BODILY INJURY(Per accident) $500,000 AUTOS ONLY AUTOS y X HIRED X NON-OWNED PROPERTYDAA E $100,000 AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAO _ OCCUR EACHOCCURRENCE EXCESS UAB CLAIMS-MADE AGGREGATE $ DED , RETENTIONS $ A WORKERS COMPENSATION WCC-500-5000706-2022A 12/3/2022 12/3/2023 X PER OTH- RTE FR AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE El.EACH ACCIDENT $100,000 OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) EL DISEASE-EA EMPLOYEE $100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth 1146 Route 28 ALIT ED.REPRESENTATIVE South Yarmouth MA 02664 / rJ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD •:•^1.11,1:10.1Mi :i , „.. IMF . : ;_ft .i7TA311Ptt.); p„ -:;5A t,7;-.:.; eF3r1L.1=7),1 514 '04 CIIOPOW>P- 3P-A157-I'"!5; ).'7;' !A ••'7.;rj :,50;;;;;.:.4 „ y T:7,ikt .;:';.*193414,18W i.14•11t.K.:71 • ; `Tr; ';iti„,;;A-ri;" r 7)7'it 5.151! 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