HomeMy WebLinkAboutBLDTR-23-006053 _=', /0-YaR GOWN O sYARNIOUTH
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.e. io BUILDING DEPARTMENT Permit Number 819D 7--,
p� C 1146 Route 28, South Yarmouth, MA 02664
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�+`���M+TA „ �„ 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued p d 10153
Expiration Date cr.., 1�/dq3
$50.00
TRENCH PERMIT
Pursuant to C.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant Phone Cell
C�ct,e anc `lr tt1C,,,J,
Street Address \)t 3t1 7 GI Ito
ity/Town MA ZIP
Aitiiu5Pp, - C2 39
Name of Ears! (if different from applicant) Phone Ceu
Street AdfrresQhn (1u(
4(65 \i\JeDt-164_vrnOuli1 12.61 401 - --(o3-3490
City/Town ,M
} A I ZIP
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Name of Ownerls)of Property CeU
Me-N-t-o --781 s89c9
Street Address
) vie esn-
City/Town MA 1 ZIP
Other Contact I Permit Fee Received No( ) Yes( )
Description,location and purpwe of proposed trench:
Please describe the exact location of the proposed trench and its purpose(Include a description of what is(or la intended)to
be laid In proposed trench(es;pipes/cable lines etc..)Please use reverse ride if additional apace Is needed.
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BUILDING OEPARTM!_NT
Insurance Certifkata M: m pt A g,ic � �1
Name and Contact Information of Insurer.
Pilky Fxpiratinn Date: � �: � I
Dig Safe N:
2�0&-O— 1$0_ 3-1W
Name of Competent Person las defined by 52a CMR 7.02):
Jokil. (�(Aduu
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Massachusetts Hoisting License I a- ` 15 �J
�rir�License Grades 4-0i A' C ‘n ( Expiration Date: 3 I 9-9 I -�
BY SIGNING THIS FORM, THE APPLICANT. OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH,OR, BEFORE COMMENCEMENT OF THE WORE, WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORE PROPOSED.INCLUDING OSHA REGULATIONS.
G.L. e. $2A, 5211 CMR 7.06 d seq.. AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND
REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORE 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
COND(t'IONS 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 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 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.
APPLICANT SIGNATURE �j
I Vtv�v�l DATE / z ,
EXCAVATOR SIGNATURE(IF DIFFERENT)
At3\114t __.. DATE
OWE SI TURF IF D
DATE 5 Z/Z
Far C'B,lf ,.sat—De ant swim di
Patil1 A,li4irsn iv j,/eatieu he
Mal/11114A Dal.
COPIDerION O ftr A
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