HomeMy WebLinkAboutBLDTR-23-006092 m ot /e
Si •Yak TOWN OF 1 :�R1[Ol'TH �/5143 6LDTE 073
o BUILDING DEPARTNI ENT Permit Number /),d&Q qZ
,o; iy; 1146 Route 28. South Val-mouth. \IA 02664
�Y » " 508-398-2231 ext. 261 Fax 508-398-0836 Date Issued 02 Cr?'
Expiration Date
TRENCH PERMIT RECEIVED
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as am ded)MAY 03 2023
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant Terry Walker Excavation Inc Phone Ce11 13ILBING-nEF-AK FME'NT6Y
Addy PO BOX 115 508-255-8785 or 508-509-5870
StreetCity/Town MA ` ZIP
WEST HARWICH 02671
Name of Excavator(if different from applicant) Phone Cell
Street Address SAME
City/Town - MA ZIP
Name of Owner(s)of Property Phone Cell
Street Address MICHAEL CURLEY
168 CAPTAIN NICKERSON ROAD
City/Town MA 1 ZIP
SOUTH YARMOUTH 1 02664
Other contact I Permit Fee Received No( ) Yes(X)PKM - transfer
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.
TITLE V SEPTIC INSTALLATION -as per plan - BACK OF PROPERTY
Insurance Certificate#:
MPP5811 L - LIAB WCC5005011714-2023A - WORKERS COMP M1 T1737L-��TQ_.
Name and Contact Information of Insurer:
McShea Insurance Agency - Joe @ 508-420-9011
Policy Expiration Date: 02/07/2024 Liab 02/07/2023 We 08/24/2023 Auto
Dig Sate : 20231809794
Name of Competent Person Ias defined by 520 CMR 7.02):
Terry S. Walker, President
Iof2
1 Mimachusetts Hoisting License 0 HE041513
License Grade: 2A Expiration Date. 05/15/2024
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 REGULATIONS APPLICABLE TO WORK PROPOSED.INCLUDING OSHA REGULATIONS,
G.L. c. 82A, 520 CMR 7.00 et seq., 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 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 GOVERING SUCH WORK.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE
MUNICIPALITY IN CONNECTION WITH 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 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 DEFEND,
INDEMNIFY. AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYF-FS 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.
APPLI T SIGNATU
_ ''� - DATE 5-3-23
ERR S. W LKER
EXCAVATOR SIGNATURE(IF DIFFERENT)
Same DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE: 5-3-23
Michael Curley
Fort l'Ni/1 M»•me--1 i mil w rite it Aix mail)
I PERNI/T t mown En nit— ]
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