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HomeMy WebLinkAboutBLDTR-23-005854 P11 V/z//1-3 TUtti'N 4F l":�R1[Ql'TN13C"-,b7�-a3-- (47+7t4kst\I .. ,� c BUILDING DEPARTMENT Permit Number 0, cY51--/ - ,` . 1146 Route 28. South 1'artnouth. NIA 02664 Date Issued 0 o7q043, »�** ti 508-398-2231 eat. 261 Fax 508-398-0836 Expiration Date 5-d-U ir-- -:- - TRENCH PERMIT APR 21 2023 Pursuant to G.L.c.82A §1 and 520 CMR 7.00 et seq.(asa amended) _ dUILDEAG DEFARi MENI THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CON TION _______ Name ofApplicant E11 (, 6rc714-e(c Phone Cell Street Address p3 I-ho— er 6l� c naq U _ 0 U J(c) (D a"S T) City/Town i MA ZIP c_ G r 1h aU V1 rJ - Dr)6% 5 Name of Excavator(if different from applicant) Phone Cell Street Address City/Town MA ZIP Name of Owner(s)of Property Phone 5-/ Cell Street Address -- - — 7 4i t' 1 _ 6-612 r. 3q1-() 6 Q1-O9n1 Ckyffoion MA I ZIP 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(eg:pipeskable lines etc..)Please use reverse side if additional space is needed. 11 n S4S1 t\ Se, :t ScySkfil i it I 1 Insurance Certificate 0: _ � t4/GC— Soo 8o-o&-v' 7a?6 -' Pao Name and Contact Information of Insurer: Policy Expiaataon Date. 4 ----- 19411,23 Dig Safe li: ' azia.3 ( a4 0183 1 Name of Competent Person(as defined by 520 CMR 7.02): Lc1-i lzi1 /� 1 of Mataankusetts Hoisting License* H.15-.0.aVG73 id)301aq License Gee:` Id 1L a' i Lc -I-V _ Expiration Date: BY SIGNING THIS FORM.THE APPLICANT,OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCF 'OF THE WORK,WILL BECOME FAMILIAR WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS, G.L. c. $Z , 5 CMR 7.N 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 THEREWfTH IN ALL RESPECTS AND WITH TIM 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 MUNICWALTTY TO ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE CONDITIOM 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 BITT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF THIS PERMIT,IMIPECTIONS 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--I ,--DEAI Ij LOSS,-OR DAMAGE- TO ANY PERSON OR G- THE---WORK-- CONDUCTED UNDER THIS PERMIT. APPLICANT SITTURE /_ ? ' -'-, ` DATE ( 0 —o � EXCAVATOR SIGNATURE(IF DIFFERENT) DATE OWN ATUjjRE(IF d DATE: 1 --. -.- - _ .. ,lA l _ For t1 flos.saw--Oa not write ati dila sett Bair #Sc APl liw!"e�ie LOSielifillatiMR Alt v - • 2of2 Commonwealth of Massachusetts Division of Occupational Licensure Ha glif ger HE-028673 z 1pires:12/30/2024 LAURENCEitE ' s 8 NORTH STr � DENNIS PORi�MA rbti0l.LVd1��y Commissioner di ea K. biters - 9 Engineer Restricted to: HE-2A-Excavators DIG SAFE Call Center:(888)344-7233 In case of accident call: (500)820.1444 Contact OPS1:(617)727-3200 or visit www,mass govidpUopsi ©® AC CERTIFICATE OF LIABILITY INSURANCEDATE(MMIODIYYYY) `,,,,,,- 11/16/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT RogersGray, Inc.-Kingston Branch PNMorEie FAX 63 Smith Lane (A/C.No,ExH: -746-3311 (A/C,No):877-816-2156 Kingston MA 02364 ADDRESS: mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC(I INSURER A:Associated Employers Insurance 11104 INSURED REID&LA-01 INSURER B:West American Insurance Co 44393 Reid&Laurence Ellis dba Ellis Brothers Construction 23 Enterprise Rd, P.O.Box 59 INSURER C:Arbella Protection 41360 Yarmouthport MA 02675 INSURER 0: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2021067994 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LT RR TYPE OF INSURANCE MSSC WYD POLICY NUMBER (ADL SUM POLICY IDCDO IYYYY) (MM/IDDOIYYYTY) LIMITS B X COMMERCIAL GENERAL UABIUTY BKW58371201 3/1/2022 3/1/2023 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADE I X I OCCUR PREMISES occurrence) $100,000 MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE UNIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY E 0. LOC PRODUCTS-COMP/OP AGO $2,000,000 OTHER: $ C AUTOMOBILE LIABILITY 1020002607 6/9/2022 6/9/2023 (E ED SINGLE LIMIT ' $ ANY AUTO BODILY INJURY(Per person) $250,000 OWNED X SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $500,000 X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $10(1,(>DO $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WCC-500-5000706-2022A 12/3/2022 12/3/2023 XTH- AND EMPLOYERS'UABILRY Y/N STATUTE ER ANYPROPRIETOR/PARTNERIEXECUT,VE E.L.EACH ACCIDENT $100,000 OFFICER/MEMBEREXCLUDED? NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule.may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth 1146 Route 28 ,w� REPRESENTATIVE South Yarmouth MA 02664 I ,.ram7„....a.,....____ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD