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HomeMy WebLinkAboutBLDTR-23-005489 c&--7 ol'•'.k TOWN OF VARNIOUTH Perm C N tuber 3 -do s .r- O BUILDING DEPART TENT cs( ;+ ! ) 1146 Route 28. South 'Val-mouth, MA 02664 Date Issued t ,.,. N..w'y S' 508-398-2231 ext. 261 Fax 508-398-0836 �- -�` ' Expiration Date TRENCH PERMIT Pursuant to G.L.c.82A §1 and 520 CMR 7.00 et seq.(as amended) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant Phone Cell IF II►s 4ro�rs �� 6a 6d3) Sires!Address �, =3 l h�r i r►S2 1�� � � MA i ZIP Cityfrown � � _ - not � 1 G�7S oh cuY� if Cell ame of Excavator( different from applicant) Phone Street Address Citylrown I MA ZIP . Name of Owner(s)of Property Phone Cell David Burack ' Street Address 7 Lexington Ln. 17 4-- 3 t3 ( 3 Yarmouth Port,MA 02675 Ckyfrown MA i wr Other Contact I Permit 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. V)Pk/ -t chi iv 1191- `-�- / RECF VED V'�/`7` -4- til r am(/ 1 APR 0 4 2023 i - B0E-DING DEPARTMENT g. y Insurance Certificate th wcic,-. . 00 - S O66 o 76 ei - )6 0; j Name and Contact Information of Insurer: t '15,5 0 c h Dn. r 1v 1 S ' , urkn C-2. ---- Policy Expiration Date: 1i f A IA a- Dig Safe f:i AO a 3 lap 0 ) Lf Name of Competent Person ias defined by 520 CMR 7.02): Lk r►y, Izti )S 1 of 2 NiMaisadinsetta Rados License p-0a8673 License Grade: N E-ao I-YC9V�i f or S E: Z� ° BY SIGNING THE FORM,THE APPLICANT,OWNER,AND EXCAVATOR ALL ACE.WOWLEDGE 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. c. $M, S20 CMR 7.SY et veg., 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 APPLICANT TO FOR THE PERMIT AND THE EXCAVATOR TO UNDERTAKE SUCH WORK OIONSWNED OWNER AUTHORIZESWN THE ARTY OF THEE OWNER, AND ALSO, FOR THE DURATION OF CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONITOR AM) INSPECT THE WORK FOR CONFORMITY WTITI THE CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH WORK. THE Y TO REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE MUNICIPALITY IN CONNECTLON WITH THIS PERMIT AND THE WORK CONDUCIED THEREUNDER, INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CON DTTIONS OF TIC PERMIT,DOPECTIONS 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 DEPEND, 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 -407)0/404 — DATE /^ 3o— a� EXCAVATOR SIGNATURE tIF RENT) DATE ., OWNER'S OE DIFFERENT) DATE: I 30/ 3 - F+rrttwrwo•sae--tNrad arise i We,media' mom APPLY t'D B1 Date . • PERMITTING AUTHORITY 2 ©f2 ACO CERTIFICATE OF LIABILITY INSURANCE DATE;1 QD2,YYYY► THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACTNAME: RogersGray,Inc.-Kingston Branch BiNc.No, 5pg.746-3311 (FiAAX No);877-816-2156 63 Smith Lane EMAIL Kingston MA 02364 ADDRESS: mail rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Associated Employers Insurance 11104 INSURED REIDBLA-01 INSURER B:West American Insurance Co 44393 Reid&Laurence Ellis dba Ellis Brothers Construction 23 Enterprise Rd,P.O.Box 59 INSURER c:Arbelia Protection 41360 Yarmouthport MA 02675 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2021067994 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN SR TYPE OFt/D ADM SUM POLICY EFF POLICY EXP LIMITS INSURANCE ,INSD W POLICY NUMBER IMMIDD/YYYY) (MMIDD/YYYY) B X COMMERCIAL GENERALLIABIUIY BKW58371201 3/1/2022 3/1/2023 EACH OCCURRENCE $1,000,000 X PREMISES(EaRENTED loam ence) $100,000 CLAIMS-MADE OCCUR MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY I I PECOT- LOC PRODUCTS-COMP/OP AGG $2,000,000 $ OTHER: COMBINED SINGLE LIMTr $ C AUTOMOBILE UABILITY 1020002607 6/9/2022 6/9/2023 (Ea accident) ANY AUTO BODILY INJURY(Per person) $250,000 OWNED X SCHEDULED BODILY INJURY(Per accident) $500,000 AUTOS ONLY AUTOS PROPERTY DAMAGE X HIRED X NOUN-OWNED (Per accident) $100,000 AUTOS ONLY AUTOS ONLY $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ — EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WCC-500-5000706-2022A 12/3/2022 12/3/2023 X sT TUTE OTH- ER AND EMPLOYERS'UABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE El.EACH ACCIDENT $100,000 OFFICER/MEMBEREXCLUDED? NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L,DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth 1146 Route 28 Au r..,n,. ,REPRESENTATIVE South Yarmouth MA 02664 sir. vosii z..a.,r.___......_...._ .... 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts IIPDivision of Occupational Ucensure Hoiigailii ger HE-028673 z spires:12130/2024 LAURENCE! E ,= .c 8 NORTH STr } lll' DENNIS POI }M1 yOf.L��L•��, Commissioner 4 Cam . �Fmc Hoisting Engineer Restricted to: HE-2A-Excavators • DIG SAFE Cali Center:(888)344-7233 In case of accident call: (808)8201444 Contact OPSI:(617)727-3200 or visit www.inass.govIdpiropsi