HomeMy WebLinkAboutBldtr-23-002467 1UWN OF YARMOUTH awr
/ t ``, BUILDING DEPARTMENT Permit Number
�g y 1146 Route 28,South Yarmouth, MA 02664
508 398 2231 ext. 1261 Fax 508-398-0836 Date Issued t0wewte w9`,,:�
Expiration Date .. `1l5
'n 50.0 I
TRENCH PERMIT RECEIVED
Pursuant to C.L. c. S2A §1 and 520 CMR 7.00 et seq.(
as am:nde4 ov 01
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSWDER�I t ZO22
Name of Applicant BUILDING DEPARTMENT
t(ogo f3 Ova Phone -0 4 c2(20- 3�'
Street Address
Ci (Town M. ZIP
Name of Excavator(if different from applicant)ctAi
Phone Cell
Street Address 5A M
City/Town AMA i ZIP
Name of Ownerts►of Property j�(� Phone
Street ddres�e C LOC' /AL) Cell
5ZD 6tkeke
City/Town I MA i ZIP
s•- lAL urd frol of
Other Contact TPermit 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.
EPTIC- Zt SC P4E.Liecm
KEIAR
Insurance('ertifkats M:
Name end Contact Information of Insurer:
Polky Etpiration Date: � i •- , ---- -
ZL- IDZL
Dig Sale N:
,Name of Competent Person as defined by 520 C11R 7.021:
(?'RyettiU, S u
1oft
Alesseelluseres Hoisting Lkerrse if 1-1-E -
License Grade: f4 E- pirat o Date: r— �= .),G
Ex ;21—)N
BY SIGNING THIS FORM, THE APPLICANT. OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF THE WO BEME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED.INCLUDING` OSHACOREGULATION&
G.L. a VA, 520 CMR 7.01 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 WORE 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 COVERING 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 REQUIRJEMITIVTS 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 OR 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.
APPLE 'SI NA RE
DATE 16 -
EXCAVA SIGNATURE(IF DEFERENT)
DATE Ir. 2c2
NEWS SIG lURE I IF DIFFERENT)
-- DATE: ; L Z _ _ ZZl Z Z
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