HomeMy WebLinkAboutBLDTR-23-003805 i
-- Y - TOWN OF YARMOUTH
BUILDING DEPARTMENT Permit Number .-- .-- '
0
' 1146 Route 28,South Yarmouth, MA 02664 LP,� ^4. 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
Expiration Date
$50.QO
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 Phone Cell
Z- ^C1.iC- CC,16 C YCtc L& ill\ 9-Fe(- 7�-cf3cl
Street Address
I Cit4c1hefty v—ttif o I Email Address:
City/Town MA ZIP
I`�ccf'C,.,II k_ 07639
Name of Excavator(if different from applicant) Phone Cell
Street Address
Email Address:
Citylrown MA ZIP
k°-eAlticese"Ci
NaameofOwnerlsl of Property Phone Cell
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Email Address:
Cky/Town MA ZIP
Other Contact 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 laid in proposed trench(eg; pipes/cable lines etc..)Please use reverse side if additional s is ---------^--r
JAN 112023
%, 1l ,.I
BUILDING DtPARTMENT
CV1 4
Insurance Certificate N:
A/W ( ' '/
Name and Contact Information of insurer:
11 X i t'1 C>G Crm eC1 c �'Gt 6 (?-Li _..
Polky Expiration Date:
Dig Safe It: /Z C/2023
Nam? Competent 1as defined by 520('MR 7.02):
I,- A
(.1)(
t A.
' I Name of Competent Person(as defined by 520 CMR 7.02):
Massachusetts Hoisting License# l.4 _ 1,59-ear
License Grade: 2/"±-/ / C Expiration Date: //Cf. /23
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 A THE
EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO, F R THE
DURATION OF CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIP TY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY H 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 CONDITIO S OF
THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES TAKEN B THE
MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS F 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 EFEND,
INDEMNIFY, AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEE FROM
ANY AND ALL LIABILITY, CAUSES OR ACTION, COSTS, AND EXPENSES RESULTING FROM OR ARISI G OUT
OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNATURE
9 _ -> DATE / / (2(Z3
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EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
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