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BLDT-23-2056 TOWN Wi YAKMOU i'II L :1)7- o BUILDING DEPARTMENT Permit Number Z 3 ` S a $ ' 1146 Route 2S,South Yarmouth,MA emu5m�a 0 :a se ext.lztst Fax st�s Date Issued Expiration Date $50.00 TRENCH PERMIT Pursuant to G.L. c.82A§1 and 520 aviR 7.00 et seq.(as amen .. . . PER114Ii?MUST BE MIX COMPLETED PRhIR TO"CQTDRN' MAY 2 5 2023 Name of Applicant iu1 c #r"1C �tr� phone Cep BUILDING DEPAFTMENT e CM Sic er f s c 775-ata BY — Street — 'D50 � Email Address; Cityrraxn MA ZIP t�t�kat�hC � Ck.ato t� Nacre ofExcavator titdifferennt from applicant) ` Phone• CeII Street Address Email Address: Cityrrown MA ZIP Name of Owner(*) Property Phone Cell Street Address? C or\oly nee -)y-altv4 il�cb �Jlo s 't-tee Email Address: Cltyrrown J MA Zip w l©1ci C,U s-� (3c��7� Other Confect j Permit Fee Received Not ) Yes( ) p«terip aa,location andpro'poapose ofposed Diu 'tease describe the met location of the proposed trench and its purpose be (include a description of whet Is(or is intended)to hdd In proposed trench(eg;pipesicable lines etc.)Pierge use reverse side if additional space is needed. fre a'r91' 0741 i Insurance Certificate 0: 7 P 9 (13!) ;Yams and Contact Information of Insurer: d IJ�°r t �C�faUe PG Q3Z01- ICkCia VVIOCini -MA oato \ policy F:xplrsdon Date: Dig Safe'F: ao&r)- Q11,()Wo Name of Competent Person t as defined by s20 CMiit 7.02i Pal t\ 1 of t‘,Tanie of Competent Person(as demised by 520(MR 7.0 ): • Paul morYt n Massachusetts Hoisting Liege# }? 0co *j7 License Grades \C.,QA A Expiration Date; 5/VI I<z 3 BY SIGNING THIS FORM, THE APPLICANT,OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CI RTIFY THAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCOM/sIT OF THE WORK,WILL BECOME FAMILIAR WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS, G.L. e. 82A, 520 CMR 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 'rnE. 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 THE MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER, INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITION OF tIDE PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES TAKEN BY Tait 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 1VIUNICIPALIT . THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY 1 T Y TO DEFEND, INDEMNIFY,AND HOLD He RM* ee THE MUNLCIPA.LITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM ANY AND ALL LIABILITY,CAUSES OR ACTION,COSTS,AND EXPENSES RESULTING PROM OR ARISING OUT OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT. APPLICANT SIGNATURE DATE .5'?, — EXCAVATOR SIGNATURE OF DIFFERENT) DATE OI?VNER'S SIGNATURE OF DIFFERENT) DATE- { a'"7 ; r , ..s ���at IP ,,9 +,ra l �- �..,� -} _ 7t31".j. � � - t _ a ; S ins. i s y rs a 4 ; 'y c�' ! S +1 ,i t- d ,h a •