HomeMy WebLinkAboutBLDTR-23-002312 , Y .._ TOWN OF YARMOUTH 1�► �-i e� /�/Z�/
%, BUILDING DEPARTMENT Permit Number Aiv 77Z- _
Q_ .7�`g 1146 Route 28,South Yarmouth, MA 02664
508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued 6 4, 3/)—
Expiration Date Cbg I g 7 2
RECEIVED
TRENCH PERMIT
Pursuant to G.L.c.82A 11 and 520 CMR 7.00 et seq.(as amended)our 27 2022
THUS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDURA
BUILDING DEPARTMENT
Name of Applicant Q ,tr ly.C(,ocA� G� PhOne Ceu r- -
Street` o t34:757. 5661
CiOrtown MA ZIP
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Name of Excavator tit different try app cant) Phone Cell
Street Address
CityfTown MA ZIP
Named'Ownerls)of Property -Phone Ce.
Street Address �—i aye(r 49c.r Ae0A
Lc1 co5kree\- GO $�5�
Cityfrown MA ZIP
9\OCYCX4,rA. v L333-1 6
Other Contact I Permit Fee Received Not ) Yes t
Description,location and purpose of proposed trench:
Please describe the exact location oldie proposed trench and its purpose(itched,a description at whet is for is intended)to
be laid he proposed trench leg;pipes/eable lines etc..)Please use reverse vide it additional space is needed.
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Insurance Certificate e}s 6
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Name sad Contact information of insurer:
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Mossodousetts Hoisting License E 14-C t-253Lt 5-1
License Geode% Explration Daft: 81 CO I 1017)
BY SIGNING THIS FORM,THE APPLICANT,OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WTTH,OR,BEFORE COMMENCEMENT OF THE WORK,WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS.
GI. C. SM, 520 CMR ISE ei 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, Ammons PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND maser THE WORK FOR CONFORMITY WITH TILE
CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH WORE.
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 WT111 THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF
TIDE PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THFREWTTIL AND MEASURES TAKEN BY THE
MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO
COMPLY THEREWMI INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED
NECESSARY BY THE MUNICIPALITY.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE„MOTTLE 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 SIGNATURE
Z,- --,-'"--- DATE
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGNA (IF DIFFERENT)
1 i'''-(`" CCDO 0 N.,-- 44 1.-"- DATE: I 0 117.8:,0,..-
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