HomeMy WebLinkAboutBLDTR-23-005621 TOWN OF YARMOUTH
'is BUILDING DEPARTMENT Permit umber s‘
O 1146 Route 28,South Yarmouth,MA 02664
! ,�, '. 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
Expiration Date
$50.00
TRENCH PERMIT
Pursuant to G.L.c.S2A 01 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT muff BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name at ApplkaIk Q e4 r 1'i E:#'1 e'jCC a L f�f�1 U [ALL Phone Ce8
Street Addis. `"�� \J ` H33 7.5—
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aty/Townu MA ZIP
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Naar of EscsYstor tit different from applicant) Phone Cell
Street Address `Cle rim
Cityllown MA I ZIP
Name of Ownerts)of PtoPerty -DC/Jl1 a n hold( Peowe Cell
Street Address
70`7 5 (, iuh al-
City/Town MA i ZIP
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Other Contact I Permit Fee Received No( ) Yes t )
Dweriptioa,location and purpose of proposed trench:
Please describe the exact location of the proposed trench and its purpose(include a
be laid in proposed trench testdescriptionace of what b(or b intended)is
� pipet/cable lines etc»)Please use reweiae side if additional apart Is needed.
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Insurance certificate pa .
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Year and Contact information of Insurer: 1Jb 1 G�� ]/1
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Pow Expiration fate•. /—
iMIS." -51 0 L-19Y?-
f Name of Competent Persos/as defined by 528 C tilt tilt:
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IT" MR POEM,THE A!'PUCANY,Off.<At EXCAVATOR ALL ACENOVII1DGE AND C"RIWY
TRAY WWI AM FAMILIAR my,OR,moms cebiliascutorr Of IRSWORE,WILL BECOME EAMH.IAR
WITS ALL LAWS:AND IRGULAlt ONM APPLICABLE TO WORE PROPOSID,UUCLtlDOIG(NIA FMOUTA
G.I. e, tlt , !* CMtt 7.0 st soo, AND ANT AVPL/CAIU MUNICIPAL ORDINAN CU, DY- AWS A O
NDCIILATIMill APS 11XY COVENANT Alai ASSISI TRAY ALL.WORE MVO Oen TI l PVIIMST WIESD FOR
EOM MOIRE WILL COSILY TiSRE ITR DP ALL'RICIFE ll AND I Ill TU copernots SET PORTS
THE uNlDDIMOI tla tl AMMON TISK APPLICANT TO"APPLY FOR TEE PERIM AND°TIM
EXCAVATOR TO wiper/Au SDC$ wont ON TUX PEOPUI?Y OE TYi OWNER, AND ALSO* POE Tin
DIARAISON #F ORESIODC11014, AUTIONIEGES PIDISOMI ISLY APPOINTED EY" 'tom mummit.rrY TO
EMI" IRON TIM PROPISTY TO MOIRI0R AND INISPIXT US WOOS 10R COMORMMTIT WITS THE
CI 'KJISK ATTACKED ARE THE LAWS Ate)RIODEA110101COVEIUNG MICH$14)1UL
TEE VIONDIACOMD APPL.ICAIT,OWNER AND EXCAVAT OE AGM JOINTLY AND SEVERALLY TO
IMWEIVIIRTRR IMPECIPALITT MANY A15 ALL C WIE AND '40/10U11lf BY TIE
t1iTCIPAt YYAt Ai CONIMSCIKE1 WIT*TW.PrnearAmo Tin WOWS COtQ .OUCTSO flStlJNDIE ',
QIWI IND WI'NOT LIMED TO IIIIRSICEIG TES magtavamorra or'TAT*LAW AI0 CO41101101411 OP
Tali *OT,INITSCTXXO WEE TO ASSUSISCODWILLINCII TIOUIDWITX A1D►&OSMIUM TAXISI SY TIIE
UtmpAL0 V TO P'WIWT Till PUBLIC WEISE Ian ASPLLCANT OWNER OR EXCAVATOR RAP TAILED TO
COMPLY T—III INCLUDING FOLK"an Arta AND WISER IUSIEDIAL MEASURES DIDEMED
MICESEAEY EY TIE MIBOCEPALITY.
"['NEIMIN#IIGIOD APPLICANT,OWNER AND EXCAVATOR A Y AND SEVERALLY TO DEFEND,`
DMIDESOY,AND*OLD RARMLt tR 115 MUMSCWALITY AND ALL Olt ITS A(MIR`T AND amiu 1Cm nOM'
ANY MS ALL UA*ILtT Y.CAUSES OR ACTION,COSTIL AM) IUDIVLITIN1 f'ftC M OR AMINO OUT
or Asy DeGal'. DEATH, wo,' OR DAMAGE it R TO ANY PIlEON OR PROPERTY DURING TIE WOE*
CONIDUCIED URDU TM*PERMIT.
APIPLWANT SIGMA IRE
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EXCAVATOR SIGNATURE"tit fLEL ERR't4T)
I DATE
OWNEW NATURE I'IF DLITE
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