HomeMy WebLinkAboutBLDT-23-2055 (2) •
017Yq?4 TOWN OF 1 ARMOUTH-1
! o BUILDING DEPARTMENT Permit Number 6 'DT -0 3 -
hs /t ryE 1146 Route 28. South Yarmouth. MA 02663
Y � .fir, :A8-398-2231 ext. 261 Fax 508-398-0836
Date Issued 5 S--
geirieoi
Expiration Date dt 3/ 9 9
RECEIVED
TRENCH PERMIT
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as anlen4de +Y 26 2023
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION 1 L DING DEPARTMENT
Name of Applicant o' S {X,63re 11,0 y S Cc 5$- Phone Cell
Street Address
a3 rLna gig, OO - 36) 6a37
City/Town 1WA I ZIP
d- Pc9& 1 5 .
Ns of Excavat (if different from applicant) Phone Cell
Street Address
City/Town MA ZIP
1
Name of Owner(s)of Property Phone Phone Cell
(V7lf / IV'Or c
Str..t Address 6 d 3--_ S L o Gilts.
/6-1 .i 5 b`p.n a r►t
City/Town ,/_ oc MA I ZIP
SGL(-l r l �1 /�'L- tnv { c' 69 2 S
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.
Ste i;r;
Insurance Certificate#:
iv CC-- C'OO — S Ci 0a(j -70 9tYa
Name and Contact Information of Insurer:
SS cdi i< k1-1. I ! mot- 'Lv mm
Policy Expiration Date: l 3 g3
Dig Safe it: ;d33 2OC) g.36
Name of Competent Person(as defined by 520 CMR 7.02):
Lq v T?4 "11
1 of 2
Massachusetts Hoisting License if 1/ r— 07-4. � `
AlaLI m*Grade: Expiration Date:
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. S7A, 52@ CMIt 7.40 et seq,, AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND
REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER TIE 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 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
OP ANY INJURY, DEATU,-IOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APPLICANT SIG
DATE
EXCAVATOR SIGNATURE(IF D RENT)
DATE
OWNER'S SIGN (IF DO1KEItENT)
DATE: l 1
Fart *we mow--Hisnof . sectilin
•
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Commonwealth of Massachusetts 1
IPDivision of Occupational Licensure
Hotalliggif per
HE-028673 z spires:12130/2024
LAURENCE! E hi',
8 NORTH ST? t
DENNIS PO04MA,
tiOf.LVd:V .)
Commissioner char"
Hoisting Engineer
Restricted to:
HE-2A-Excavators
DIG SAFE Cali Center:(888)344-7233
In case of accident call: (508)820 4444
Contact°PSI:(617)7273200 or visit wawv.mass.govldpliopsi
ACCPREY CERTIFICATE OF LIABILITY IN OA n
SURANCE
11
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HO tLDER 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 ADDmONAL INSURED,the policy(les)must have ADDMONAL INSURED provisions or be endorsed.
if Ss tBRO Ae TION
IS
WAIVED,
subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
PRODUCER
rights to the Nye holder In lieu of su a dor It{sk
RogersGray,Inc.-Kingston Branch NAME:
63 Smith Lane o.�:508446-3311
Kingston MA 02364 F .Iro) 877-816-2156
m8512 Y-cam
INSURER(S)WORMS COVERAGE NAIL S
INSURED MUM A:Associated Employers Insurance 11104
Reid&Laurence Ellis dba Ellis Brothers Construction REuXuA-0t INSURER Et:West American Insurance Co 44393
23 Enterprise Rd,P.O.Box 59 INSURER C:Arbefa Protection
Yalmouthport MA 02675INSURER D:
41360
SOURER E:
COVERAGES SURER F:
CERTIFICATE NUMBER:2021087984 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED 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 18 SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
iRADDLVUSR
POLICY Err POLICY EXP
LIR/ TYPE OF INSURANCE um tom, POLICY MOEN a X COMMERCIAL GENERALUMW( BKW5S3T1201 �Ml . MOTS
3M/2022 9/1l2023023 1.000,000
DAMAGE 70 RENTED
1 OCCUR $
PREMISES Ms occurrence) 100,000
MED EXP(My one person) $15,000
GEN1.AGGREGATE UST APPLIES PER: PERSONAL S AOV INJURY $1.000,000
X ....,ri Jar ri LOC GENERAL AGGREGATE $a,000,000
OTHER: PRODUCTS-COMP/OP AGO $2,000,000
C 1020002e07 $
ANY AUTO LV9N2022 802023 f SINGLE LIMIT $
—H OWNEDS X A e�LYI Y(Perpoem) $250,000
X AUTOS ONLY X ScHEDuLED
ED A�UTOS �YONL
(Peteaddent PODILY INJURY(Per accident) $500,000
$100,000
EXCESSUMBRE LU UAs I I — $
ExCEBELIBcumeg.mADMCUR /OCCURRENCE $
DED I RETENTION$ AGGREGATE $
I
A MIORKER8COMPENSATION WCC^50480007062022A 1p�R $
AND EMPLOYERS'LIABILITY Y 2J312Ce2 12/3/2023STA X I um I I ER
ANYPROPRIETORIPARTNERIEXECUTNE
yro esss ht NM tuDEDT NIA El..EACH ACCIDENT $100,000
DESCRIPTION OF OPERATIONS below
E.L.DISEASE-EA EMPLOYEE 5100,000
E.L.DISEASE-POLICY LENT $S00,000
DEscRwriON OP OPERATIONS/LOCATJoNS t VEHICLES(ACORD lot,Additional Rem Sch.duhe,may be aUed,ed hrmore space is remand)
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, PICITICE WILL BE DELIVERED IN
Town of Yarmouth ACCORDANCE WITH THE POLICY PROVI
1146 Route 28
South Yarmouth MA 02664 5ESENTATIVE 7,00444.4,
ACORD 25(�16/D3) The ACORD name and01988 2015 ACORD CORPORATION. All rights fired.
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