HomeMy WebLinkAboutBLDTR-23-003206 rn ei,t. a_A / /4/Z2
847rZ4 TOWN OF YAR1IOUTH
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k yt.\p BUILDING DEPARTMENT Permit Number l)&326,(p
t, )yE 1146 Route 28. South 1'artnouth. NIA 02664
�' .un I� ,4 +()R-3�8-2231 eat. 261 Fax 5f18-3 8-0836 Date Issued t 111717
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''f''' Expiration Date 5'(1,CO
TRENCH PERMIT TFECO822T1
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amen di_____ _._____
BUILDINt DCF=ART;1/1FNT
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATIOi By_
Name of Applicant Phone Cell
Dig It Construction LLC
Street Address 508-432-1635 508-367-2256
22 Diamonds path / PO box 268
City/Town MA I ZIP
South Dennis 102660
Name of Excavator(if different from applicant) ' Phone Cell
Street Address
City/Town MA ZIP
Name of Owner(s)of Property Phone Cell
`1S-6 r+ a4r
Street Address
(-7 b SX.VOUfb lh 6Dr• 367 b QC)
City/Town MA ! ZIP _
l4yurini5 I
Other Contact ) 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.
In -CA) S P 1-`C S(iS a-e-m CA_}
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Insurance Certificate#: ZDNJ017376
Name and Contact information of Insurer: _.
;Eastern states Insurance - 781-642-9000
Polley Expiration Date: 5/18/23 _.
Dig Safe it:
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Name of Competent Person(as defined by 520 CMR 7.021:
'Kerry Sullivan
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Masesdurseua Hawn maim; HE-153873
Lkeaee Grades HE-2ARim'Won Diu 2/24/24
BY
BY SIGNING THEY ARE FAi A THIS FORM.THE APP UCANT,OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
STD.OR,SWORE COMMENCEMENT OF THE WORK.WILL BECOME FAMILL&i
WITH.ALL LAWS AND REGULATION APPLICABLE TO WORKOsED;INCLUDING ,
G.L. e. t2A, S20 CM7.00 d sec AND ANY APPLICABLE MUNICIPAL OSHA BYCES, -L4W AND
REGULATIONS
SUCH WORK WILL D THEY COVENANT AND AGRFE TIIAT ALL WORK DONE UNDER THE MOSHE ISSUED FOR
BELOW. COMPLY TES IN ALL RESPECTS AND WITH THE CONDEMNS SET FORTH
TIE
UNG DE,IGNED OWNER Avnioauzss TRB APPLICANT TO APPLY FOR THE PERMIT AND THE
DURATION OE OUNDERTAEE SUCH WORK ON THE PROPERTY OF THE OWNER.AND ALSO,FOR THE
ENTER UPON THE PROD TO AND DEFECT DULY Aungoinzcs VERSOS E FOR CONFORMITY APPOINTED BY THE ACHY WITH THEPO
CONDEMNS ATTACHED HERETO AND TIM LAWS AND REGULATIONS COVERING SUCH WORK.
THE
APPLICANT,OWNER APB)EXCAVATOR AGREE
R�URSET� FORAM/ANDALLCOSTSMCI PEN.YANDSEVERAII.YTO
NSES INCUIMM)BY ISE
MUHICIPALTTY IN CONNECTION WHTHIS rather AND THE WORK CONDUCTED THERE'RE/ER,
ITHM
NCLUDING RUT NOTLBITTEDTO MWORCING.DM REQUIREMENTS Cfff STATE LAW AND CONDTTEMSC r
MUNIC)RM T, N MADE TOASSESB CET TR,AND MEASURES TAKEN BY THE
COMPLY T IIWlT$ POUCE THE INMUC
DVIApHEREg AND OTHER REM THE APPUCANT OWNER LEAEXCAVATOR HAS FAILED ID
NECESSARY BY THE MVNICIpALny.
THE UNDERSIGNED
INDESINIFY,ANDROW
APPLICAN:OWNER AM)EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
HARMLESS THE MUNICI AUTY AND ALL OF ITS AGENTS AND EMPLOYEES
ANT AND ALL LIABILITY,CAUMS OR AC7fON.COSTS.AM)EXPENSES RESULTING FROM OR ARMING OUT
OF ANY INJURY,
CONDUCTED UNDER THIS LOBS, OR DAMAGE TO ANY PERSON PROPERTY DURING THE WORK
PERMIT.
APPLICANT
DATE 4
EXCAVATORSJGNATURE DIFFER
BATE Id 7 PA
OWNER'S SIGNATURE(Hr DIFFERENT)
DATE:
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f ",uanvae�7 Bat ulIM:
OF
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