HomeMy WebLinkAboutBLDTR-23-005335 .Y _. TOWN OF YARMOUTH i�' ��73 . 40 5335
1 1.4= a BUILDING DEPARTMENT Permit Number
,Inv,,Inv,s, 51 1146 Route 28,South Yarmouth,MA 02664
508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
Expiration Date
$50.00
TRENCH PERMIT
Pursuant to G.L.c.82A 11 and 520 CMR 7.00 et seq.(as amended)
THIS PERMS MUST HE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Appliesnt 'co.w i es g a sts-r" Phone Celt
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t:Ay/Town MA ZIP
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Name of E*cavetor if different from applicant) Phone Celt
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City/Town MA ZIP
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Nacre of Owneris)of Property j Aw»¢S F�ja$1 Phone Celt
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Other Contact I Permit Fee Received Not ) Tea t )
Description.location and purpose of proposed trench:
Please describe the exact leatiot of the proposed trench and its peeper(include a description of what is(or is intended)to
be bid in proposed trench(tan pipeakahh lines ems.)Please use reverse side Daddhlonad space is needed.
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RECEIVED
MAR 2q 2023
BUILDING DEPARTMENT
Insurance Cerr�Cay 2� — --
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Nacre sad Contact Infonnstir of Insurer:
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Pall Expiration Date: C-Si"l D.Oa 3 )
1 rva Naar of Compete Pen tas defined by Slit CMS TV):
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BY SIGNING THIS FORM,THE APPLICANT,OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR Wrm,OR,BEFORE COMMENCEMENT OF THE WORE,WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATE APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,
G.L. e. 32A. 52B CMR 7.00 d seq., AND ANY APPLICABLE MUNICLrAL ORDINANCES, BY-LAIRS 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
MOW.
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 OW CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT T E 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
REMORSE 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 CONDITONS OF
THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH.AND MEASURES TAKEN BY THIS
MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FABLED TO
COMPLY THEREWITH INCLUDING POLICE MAILS 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 OF TTS AGENTS AND EMPLOYEES FROM
ANY AND ALL LIABILITY,CAUSES OR ACTION,COTS,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.
CANT SIGNATURE
DATE I 123
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE 3/27/2-3
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
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