HomeMy WebLinkAboutBLDTR-23-003059 i,'iki ie /,2t-s—��
�,o��qR �OV1VN OF YARIVIOUTH
o(. \o' BUILDING DEPARTMENT Permit Number A/4)77 -a 3
y 1i-16 Route 28,South Yarmouth, MA 02664
7A „�(y,�/2' 50E-398-2231 ext. 1261 Fax 508-398-0836 Date Issued o�m��q
v(`J�1MAT
•
���`� Expiration Date (' #i), Cp
$50.00
TRENCH PERMIT RECEIVED
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amen,
THLS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDFRATI t ) DEC 0 5 2021
Name of Applicant a..LU/O CnS/ Phone Cell BUILDING DEPART
v �I�rVC%4I U)') _ c By.__________________
y:_ ENT
Street Address C./5- .L.„_/t,.$/ /Q-/ ' U a- o`Z - S'�l Co — —
City/Towni MA ZIP
i
44.5 LS gA O Co VS'
Name of Excavator(if diferent from applicant) Phone Cell
Street Addres*
City/Town MA ZIP
Name of Ownerla)of Property t. Ciaill
Phone AS Cell
Street Address livia4;`) $S - a��- ���qt5We4 R4 .
City/Town MA ' ZIP
4 (-la(PM
o�c�y S
Other Contact LPermit Fee Received No( ) Yes( )
Description.location and purpose of proposed trench: 5 {.i6 SAS kson -k`la;2
Please describe the exact)(motion of the proposed trench and its purpose(include a descriptlan of what is(or is intended)to
be laid in proposed trench leg;plpes/cabk Hoes etc..)Please use reverse side if additional space Is needed.
Ans e_ ocu3 14 to lsooga.l S9Y-ic vk, 1-00 jis+r,'Lu.ci-;on lobs 5—axes o f
e-41 ARC 3Co lour prole bicO i CC:\-u,ser5 'log, `hoc less leudn c2;ek? conned--
)
-to /-lilt 66,pO%c oui-le/ to/LA a,///.ices5-e/t.t/ ci P✓C-Ma-e 4- ! C;tti10 t5z)
Insurance Certificate ti: to p
Name and Contact Information of Insurer:
Brae t'"ll.ctUAS_=10StA4wit -e- Pb• x ,;?S Owajoaf L) /WN SSCX 7
Policy Espiratior Date: /l� 7 Z R3 ---
Dig Safe a: `90-1 i8) a ,c/
Name of Competent Person Ins defined by A 520(MR 7
21:
_
Iot2
M-satmetausette Hoisting License i ,,;`353,2 f
•
//;/.;2y
License Grades 2/' Ex 'ration Date:
BY SIGNING THIS FORM, THE APPLICANT, OVVNER, 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. e. S2A, 520 CMII 7.00 et req., 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, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFOiRMTTY WITH THE
CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS GOVERING SUCH WORL
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 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 MEA.SUREF DEEMED
NECESSARY BY THE MUNICIPALITY.
THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDEMNIFY, AND HOLD HARMIEF.SS 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 SI RE
DATE
EXCAVATOR SIGNATU DLFEREFM
A TE AA 4'
O ER'S SIGNATURE:I IF DIFFERENT)
DATE: /.2-/-;,/,
Far CleXrww•treQ— wst_ write it
IER A1T1cki+ED If — �.-a�k� �FFM he
A Den
cortputot4 c=rai.
2o12