HomeMy WebLinkAboutBLDTRr-23-006115 "too /f/Z3
o 'Y4:4 TOWN OF 1 ARMIOUTH
�'" BUrt.DING DEPARTMENT Permit Number ,&1& i ri 3-
p; - _ 1146 Route 28. South ' Yarmouth, MA 02664 Date Issued /� '
508-398-2231 ext. 261 Fax 508-398-0836
''aee3g.r." Expiration Date M 5Li z
RECEIVED
TRENCH PERMIT
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amend(d)MAY 05 2023
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION U I L D I N G DEPARTMENT
By - --Name of Applicant D�0 ..� ®t+R co Phone Cell
hhuu MCA -471— 7 74 --2cz-387 tt--
Street Address
363 i.,21Rt
City/Town MA ZIP
y
5�� ou + it ik Z()C,c
Name of Excavator(if different from applicant) Phone Cell
Street Address
City/Town MA ZIP
Name of Owner(s)of Property Phone Cell
-W.JoE L c- 1—WA COSTA
Street Address
g V t K.t ROCK_ 1�
City/Town MA 1 ZIP
SU. VA HA O 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.
5�i i TLEN
Insurance Certificate#: GM /J 1 .30I 42.g _.2
jName and Contact Information of Insurer:
Policy Expiration Date: t Z —
Dig Safe#: 24 2=5 I Z.I
Name of Competent Person(as defined by 520 CMR 7.02):
13AYMJ � ► �-/
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Massachusetts Hoisting License 41 '�-�E I (:)2`(`t
License Grade: (cam 2.,A Expiration Irate: l i`S - 2.' �ct
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
WITH,ALL LAWS AND REGULATIONSAPPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,
G.L. a S2A, 520 CMR 7.00 et seq., AND ANI' APPLICABLE MUNICIPAL ORDINANCES, BYLAWS AND
REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR
SUCH WORT{ WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH 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 WORK.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REIMBURSE THE MUNICIPALITY FOR ANY AND A LL COSTS AND EXPENSES INCURRED BY I"II<L
MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORN CONDUCTED THEREUNDER,
INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF
THIS PERMIT,INSPECTIONS 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 TILE MUNICIPALITY.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDEMNIFY,AND HOLD HARMLESS THE MUMCIPALTTY 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.
APPLIC 'I A
DATE _ 5. 04;
EX AVAT0IGNATURE(IF DIFFERENT)
Skite DATE
OWNER'S SIGNATURE(IF DIFFERENT)
/X" DATE: „.2_13
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PERMITAPPROVEdl iw.,.:, . $_�;_-- v Alp iitI n fee.` ' .
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