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HomeMy WebLinkAboutbldtr-23-002309 /na-i le-/-- /!>/Zt/ere, , � TOWN OF YARIVIOUTH ov ''AR,r; BUILDING DEPARTMENT Permit ermit Number _ l_____ O it y 1146 Route 28,South Yarmouth, MA 02664 • �• 3„4 4' 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued . d,3�i q Expiration Date 6160 4 05020 QP9VED TRENCH PERMIT ______ Pursuant to C.L. c.82A 41 and 520 CMR 7.00 et seq.(as amen.ed) OCT 27 2022 THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSWD — ERATIO BUlLDIPJG DEPARTMENT Name of Applicant Phone By: - __- —— 0l} CU CeU Street Address 77 Z[Z -327 41 3w3 tett f-#-t -m--s t?4c�4 '-r.4.1.7 ?- n CitylTown I MA ZIP Name of Excavator(if different from applicant) Phone Cell Street Address City/Town I MA I ZIP Name of Ownorm of Property Phone AktRU1z. - G�GiC.tA 13t 77'y Cell Street Address - ' • Ckylrown /A ZIP ac�-- X S'.VAP—AC114.-jr24 Other Contact ©� ' Description.location and Permit Fee Received No Yes _ purpose of proposed trench: be laid describe the exact location otthe proposed trench and its purpose(include a description of what is for is intended)to proposed trench leg;pipes/cable lines etc_)Please use mane side if additional space is needed. 3p- Insurance Certificate 0: t Name end Contact Information of insurer. NI Es•fretless Date. • _T� Dig Safe 0: Z _ zoz�, 2.0 LI4 63 `toms of Cnmpetent Perms 1 as defined by 520 C;SIR 7.U2i: I I 1of2 Mmc#'°setts Hoisting License I }- - 12 d (17-4, • limos Grades f-i- - 4 6s ratios Date: r r` g BY SIGNING THIS FORM. THE APPUCANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT TREY ARE FAMIL AR WITH,OR,BEFORE COMMENCEMENT OF THE WORK, WILL BECOME FAMILIAR WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS. G.1- c. STA. Si, CMS 7.00 et sec,. AND ANY APPLICABLE MUNICIPAL ORDINANCES, 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 EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE O PERMIT AND THE DURATION OF CONSTRUCTION. AUTHORIZES . AND ALSO,THE Ip FOR THEO ENTER UPON THE PROPERTY TO MONITOR AND LNSPECT THE W LY APPOINTED RCONFORMTTY WITH THE CONDmONS ATTACHED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH WORK. THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND REIMBURSE THE MUNICITALTIY FOR ANY AND ALL COSTS AND EXPENSES INCURREDSEVERALLY TO MUN ICIPALTTY IN CONNECTION WITH THIS PERMIT AND TER WORK CONDUCTEDBTHZ THEREUNDER, INMS CLUDING BUT NOT LIMITED TO MEOWING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF MUNICEPAUTY TO PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWTTH,AND MEASURES TAKEN BY THE COMPLY PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAII.ED TO NECESSARY B�YYTTHEE MI;NICIPA Ty.AC=Dimas AND OTHER REMEDIAL M �DEEMED THE UNDERSIGNED APPLICANT.OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY INDEMNIFY,AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND TO SDEFEND,FROM ANY AND ALL LIABILITY,CAUSES OR ACTION,COSTS, AND EXPENSES RESULTINGARISINGEMPLOYEES FROM OF ANY INJURY, DEATH, LOSS„ OR DAMAGE TO ANY PERSON OR PROPERTY FROM OR TUEOUT CONDUCTED UNDER THIS PERMIT. PERTY DURING THB WORK APPLIC SL NA DATE - L` 2.2 CA SIG A ( EFFERENT) DATE (O— ZS - Zc)2� OWNER'S SIGNATURE(IF DIFFERENT) DATE: /a --2 Far C re-Dr ant w .,'7 allillinnilmimmemo 2 of 2 J