HomeMy WebLinkAboutBLDTR-23-003053 m eti ) /oz
,�a TOWN OF YARMOUTH
r, \ BUILDING DEPARTMENT Permit Number ,e 0 T12—
1146 Route 28,South Yarmouth, MA 02664
508-398-2231 ext. 1261 Fax 5.08-398-0836 Date Issued d,6.3O5
Expiration Date 0JL#9/)/q_w
$50.00
TRENCH PERMIT RECEIVED
Pursuant to G.L.c. 82A 91 and 520 CMR 7.00 et seq.(as ame )DEC 02
2022
THIS PERMIT' !tl 1ST BE E'U1.1.Y COMPUTED PRIOR TO CONSW ERATKIFV
Name al Applicant 6 3 ix �„4 0A W. Phone Cell By
$d}LDIN(3 UEPAki�AENT
Street Address 568 t�`}- -ob c 3
. ut g.646- rt40
City/Town MA ZIP
Name of Excavator tit different irons applicant) Phone Cell
Street Address
City/Town MA - ZIP �
Name of Owners so of Property p)1
( 6(01db oil Phone Cell
Street Address
7 Hawes IC.Urn g0o4
CkyiTown SEA II ZIP
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Other Contact 11 I Permit Fee Received No ) Yes t ) —
Description„{wades and purpose of proposed trench:
Please describe the exact treaders of the proposed trench and its purpose(include a descripdan ai whet is(or is intended)to
be Iadd In proposed trench(es;pipes/cable lines etc_)Please tine reverse vide if additional spare is needed.
t1 S- 1\&lei pr Ot Sicts;(- 54V►-t
Insurance Certificate It Z 1$ $
Name and Contact Information of Insurer
Sc,leckw t,AS.
YriNrY EiQiratlrxs Date:
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Name of Competent Persos owl dietlned by 520 C Mit 1.)2):
460- c‘
1 of 2
M'aausdi n,ts Hoisting License. HE. oUtn.°
Z,(( 12-4
License Grade: 7 A Expiration Date:
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. a FJA, 520 CMR 7.06 d soak 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 It) 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 THR
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 WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OR
THIS PERMED.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 DFF.MED
NECESSARY BY THE MUNICIPALITY.
THE UNDERSIGNED APPLICANT. OWNER AND EXCAVATOR AGREE JOINTLY 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
or ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APPLI�Z T SIGN RE
/ DATE Ir. 3" ZZ
EXC VATOR,gLGNATURF(IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
___-----.— _DATE:—
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