HomeMy WebLinkAboutBLDT-23-1- S.
TOWN OF YARMOUTH
2 o BUILDING DEPARTMENT Permit Number 31 P 7
• p ‘,.,�'y� y 1146 Route 28,South Yarmouth,MA 02664
508-398-2231 ext.1261 Fax 508-398-0836 Date Issued
Expiration Date AO53
-06
$50.00
TRENCH PERMIT RECEIVED
Pursuant to G.L. c.82A §1 and 520 CMR 7.00 et seq.(as ame )
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATI MAY 12 2023
Name of Applicant p 0 aaw.. Phone Cell u u i L[7tN G D E PA R TM E N T
Street Address '(71-SF17 77 4- -37
tti>1 (:)I --( 7 - PO4- Email Address:Rovp.,Z@ 06, 6d ,,CDs,
City/Town MA ZIP
S► VA-Ries N$4. 0244,
Name of Excavator(if different from applicant) Phone Cell
Street Address E
Email Address:
City/Town MA ZIP
Name of Owoerts)of Property Phone C.0
ik-[4£Ie 11.4ueiet /
Street Address
gg C e Z (4_ZD Email Address:
City/Town MA ZIP
S NikkottejOrg tilA 2h
Other Contact I 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 leg:pipes/cable lines etc..)Please use reverse side if additional space is needed.
Insurance Certificate If: C 30
(42.g.'3
Name and Contact Information of Insurer.
i ' i
Polky Expiration Date: i'2..-t - ZU�
Dig Safe 0: 2cL3 6o3033
Name of C omtent Person I as defined by 520 C'MR 7.02):
BRYI14) SW EE1L6-V
M'insc#nu,Hoisting Lice M lie' -- /S6.2c4
BY SIGNING THIS FORK TEE APPLICANT, OWNS
THAT THEY ARE FAMILIAR W OR,BEFORE CO AND EXCAVATOR ALL ACKNOWLEDGE AND CSRT A
THAT ALL LAWS AND WI REGULATION; COMMENCEMENT OF THE Kr
Wl CMR 7O d APPLICABLE TO WORE PROPOSED.INCLUDING l OSHARK,WILL RE BECOME FAMILIAR
G.L.REG 4 CIA NS AND nay COVENANT AND ANY AmmicABLE MUNICIPAL. ORDINAN REGULATIONS.
SUCH WORK ANT AND AGREE TRAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR
BELOW. WELL COMPLY THRRE'W'ATH IN ALL RESPECTS AND WITH THE COND SET FORTH
TH
ORTp
THE UNDERSIGNED OWNER AUTHORIZES THE UN EXCAVATOR TO UNDERTAKE SUCH WORK TONJ CANT TO APPLY FOR THE PERMIT AND THE
DURATION OP CONSTRUCTION,KES ACH THE PROPERTY OF THE a
ENTER UPONN THE q TO MONITORRI2,ER on DULY APPOINTED BYA THE R• AND MUNICIPALITYALSO, FOR TM
coNDITIONE ATTACHED HERETO AND THE LAWS waiter Ttlg WORK FORCOVERING
CONFORMITY 1�0
THE UNDERSIGNED APPLIC AND REGULATIONS COVERMG SUCH WORK. Till
REIMBURSE T88 APPLICANT, AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
R MBURSE MUNICIPALITY IN CONNECTION FOR ANY AND ALL COSTS AND
T INCLUDING CT IM NOF LIMED TO EN IOS15 CONDUCTEDF s ENSES THEREUNDER,AND THE
MUNICIPALITY INE PR :nwANC$
PROTECT THE PUBLIC CO THEREWITH,OF STATE LA W AND Ct1ND1 DTONS or
COMPLY THEREWITHPR WELT PUBLIC APPLICANT OWNER
AND MEASURESCEXCAVATOR
TAKEN BY THE
NEC SSAR'Y BY THg MUNICIPA .YPOLI AND OTHER REMFUi OR EXCAVATOR HAS PALLED TO
LPL MEASURES DEEMED
THE tGNED APPLICANT,OWNER AND EXCAVATOR AGREE
'•AND HOLD ildilIMLESS ALL LIABILITY, MUNICIPALITY AND A JOINTLY AND SEVERALLY TO DEFEND,OP ANY INIURY. USER OR A ALL OF ITS_AGENTS RD
Estmones FROM
ANY AND CON CTE UNDER TAIL P IT.OR DAMAGE COSTS,
A "R30NAND s o RESULTING FROM ARISINGUT
PROPERTY DURING THE WORK
APPLIC St NA RE f
DATE - ""�0�,2
EXCAVA . , A 7
SIG �, .y) ER6NI■�.■
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