HomeMy WebLinkAboutBLDT-23-2056- g TO VVN OF AI .0 UI`Ii. _
` BUILDING DEPARTMENT Permit Number -6
Ox �. cill y;' 1146 Route 28,South Yarmouth,MA 02664
' , "L� 50E-39E-2231 eat.1261 Fax S-398W0036 Datesued
Expiration Date
$50.00
CE
RE
TRENCH 1'E T L' ' ..
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Pursuant to G.L. c.82A 11 and 520 CM,R 7.00 et seq.(as amended) MAY 25 2023
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSiWERATION _
Name tei'Applicant a _ -BUILDING DEPARTMENT"
't'1 Phone Cad B y.-----r..
Street
ll $ Entail Address:D�C`Gt"'K;t
NoiT
Name of Excavator(if dif8rrent tram applicant) .ram Cell
Street Address
Email Address:
City/Town MA ZIP
Name of Owner(*)of Property not* cell 1
Street Address '.'!„) U.: �''` - -9�1p
,
Email Address:
City/room MA
N104-teiV l
Other Contact I Permit Fee Received No( ) Yes( )
Oeseeiption,[action and purpose of proposed trench*
Please describe the exact location of the proposed trench and its purpose(rude n be laid in proposed trench(eg pipesteable lines etc,.)Please use reseraeside'tad t�lod�� what of need f or intended)to
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1 Insurrnee Certificate 0: .7 p ve)e;vbq nqq
.Voris and(*Millet information of TnStiren CtowitrAt 4 C i
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.. Al Ex "'ration Date:
Dig Sate a: __..
Name of Competent Person t as defined by szo C NIR 7.02):
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Name of Competent Person(as defined by 520 MR 7.02):
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Massachusetts Hoisting Liconw,# 00849q*V7
License Grade:
ration Date: 5/ 1 1z,
BY SIGNING THIS FORM,THE APPLICANT, OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR.WITH,OR,BEFORE comanscraffmr OF THE WORK,WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,
G.L. c. SU, 520 awt 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
iTh
MUNICIPALITY IN CONNECTION MTH THIS PERMIT AND THE WORK CONIDUCilsi)THEREUNDER,
INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF
TUTS 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 MUNIaPALITY.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDENINNY,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
CONDUL;110 UNDER THIS PERMIT.
APPLICANT SIGNATIME
DATE TtZ
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
.010•101.11.0.011 poo....osm•
OWNER'S SIGNATURE(IF DIFFERENT)
DATE.
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