HomeMy WebLinkAboutBLDTR-23-005832 BLD 11 TOWN OF YARMOUTH
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} BUILDING DEPARTMENT Permit Number— -0057
O 4.10eY4 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 C.L.c. 82A §1 and 520 CMR 7.00 et seq.(aa amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
None et Applicant pobta_
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Street Addreva.24 6ritif idiettrh PAct 1147 O5d
City/town MA ZIP
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Name of Excavator(it different front applicant) Phone Cell
Street Address
City/Town MA I ZIP
Nam of ownerts!of Property ) /x 1st put 6mo,, phone Cer
Street era`AO Bloc �. -��=
City/Town MA ZIP
MAO did 73
Other Contact l Permit Fee Received No( ) Yes
Description,!modest and purpose of proposed trench:
Please describe the exact location tithe proposed trench and Ns purpose(faehtde a description of what is(or is intended)to
be laid in proposed trench(es;pipes/cable lines etc..)Please use reverse vide it additional brooded
_ RECEIVED.
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APR 20 1013
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Insurance Cedilksts t: WPA n 3 i1 i i - ^;L „
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Name and Contact Information of Insurer:
CM'i au ixduraxe its Ihtr 11l
Polity Expiration Dates I/I Ii.Q —
Din Sate dk 02023 /6ocu /6
.Name of Competent Person tas deQoed by S20 t'MR 7.02):
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Mawadswette Hoisting Mean
• License Grades 02 I I g _ Expiration Date: l a .
BY SIGNING THIS FORM, THE APPLICANT, OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF THE WORK,WILL BECOME FAMILIAR
WTTH,ALL LAWS AND REGULATION APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS.
G.L. e. EA. 525 CM 7.00 et seg., 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 WTru 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 CONFORMITY WITH THE
CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH WORE.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
azawamsa THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE
MUNICIPALITY IN CONNECTION Will 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 COMP IANCE 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 DEFEND,
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 UN► -+ ' IL PERMIT.
APP ` �j; 'NATURE
elit ii A. DATE 4/141022
EXCAVATO 41 GNATURE(IF DIFFERENT)
DATE
OW NATURE(IF D RENT)
a DATE:
Fir CMg1t.ate-04►eet1"AIPi,tl
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