HomeMy WebLinkAboutBLDTR-23-002812 TOWN OF YARMOUTH m a''/`� /i- l"
'"� 40. BUILDING DEPARTMENT Permit Number ALATC
p(- ,g 1146 Route 28,South Yarmouth, MA 02664
»rn�1„ ,y 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued d z2-,/ -
Expiration Date C #618
$50.00
TRENCH PERMIT
IRECEIVEDm
Pursuant to C.L. c. 82A §1 and 520 CMR 7.00 et seq.(ea am n &WV 212022
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERA t
Uil_DiNG DEHARTMENT
Noasr of ApplicantC-,� CYCILpie Street Ahdrne 3Z pc1eJ?)f "f erauE3 _:56L\
Cuy/cGO o z6v�
Name of Excavator{if different from applicant) Phone Cell
Street Address
City/Town MA I ZIP
Naar of Ownertat of ProPertr ,� �j ` Pam CtY
Street Address zell yii(rtfAls Cain
City/Town MA ZIP
WEST TIC/ADM 77�
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(es;pipes/cable Uses etc..)Please use revere side if additional space Is needed.
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Insurance C'ertilkate+t: 59D-1
`tome sad Contact information of Insurer:
+?-L-'9ucicW ‘W�. ?o`_ M,i3€-SS Pi2Y--)U3e-SU,OCEO;(119
Pe Ex Don Date:
set.,_ 0/ Y3
Nome of Competent Person(as defined by 520 CMS 7.G2):
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Whiallennett.ilakein Lkeate
License Gesdet Cv r' - /
Lspirstton Date: 1 CZS
SY'SIGNING THLS FORM, THE APPLICANT,OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR wml,OR,BEFORE COMMENCEMENT OF THE WORE,WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUUDING05HA REGULATIOI4S.
G.L. c. EIA, S20 CM* 7.10 d sec„ AND ANY APPLICABLE MUNICIPAL ORDINANCES, BYLAWS AND
RBGLI.ATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR
SUCH WORK WILL COMPLY THEI EWITR IN ALL RESPECTS AND WITH THE coNDTITONs SET FORTH
BELOW
THE UNDERSIGNED OWNER. AUTHORIZES THE APPLICANT TO APPLY FOR THE PERM T AND THE
EICAYATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO, FOE THE
DURATION OF CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNLCIPAETTY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK F R 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
RLIMBURSL THE MUNICIPALITY FOR ANY AND ALL COSTS AND MENSES INCURRED BY THE
MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCT=THEREUNDER,
INCLUDING BUT NOT Lange TO ENFORCING THE REQUIREMENTS Of STATE LAW AND CONDITIONS OF
THIS PERSifF,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES TATUM BY THE
MUNKIPALIT'Y TO PROTECT'IRE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO
COMPLY THEREWITH INCLUDING POLICE DE'TAIIS AND OTHER REMEDIAL MEASURES DEEMED
NECESSARY BY THE MUNICIPALITY.
THB UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,,
INDEMNIFY, AND HOLD HARMLESS THE MUNICIPALITY AND ALL OE ITS AGENTS AND EMPLOYEES FROM
ANY AND ALL LIABILITY,CAUSES OR ACTION,COSTS,AND EAFENSES RESULTING FROM OR ARISING OUT
OR ANY DUVET, DEATH, IAES, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK.
CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNATURE
DATE
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
_ DATE:
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