HomeMy WebLinkAboutbldtr-23-005931 in et/ le of lzu
TOWN OF YARMOUTH
BUILDING DEPARTMENT Permit Number
8(•
c 1146 koute 28,South Yarmouth, MA 02664
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508-398-2/31 ext. 1261 Fax 508-398-0836 Date Issued O
• 3
Expiration Date - r-44-cribi5L-f
$50.00
RECEIVED
TRENCH PERMIT
Pursuant to G.L.t. 82A 11 and 520 CMII 7.00 et seq.(aa amended) APR 24 2023
THIS PERNIff MUST SE FULLY COMPLETED PRIOR TO CONSIDERATION
Nam of Apparel* 3 itc,culegki 0" 1:64-- eta c By ----
nom BiTPLLAING L) PARTMENT
Sireit
Heir 98- o( c'3
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City/Tomo MA ZIP
Stxruh4,0, Ay, 02S(.3
Name of Excavator tit dieters*irate stepliesset) Mee
Street Address
City/Town MA ZIP
Name at Otalserts)fit Property lea j 6 0(wee, new 0E0
Semi Address
Alqonior. Si
City/town MA I ZIP
VI1(0.10"
()thee Contact 1 Permit Fes Ricthed No .) Yes( .)
Deseripties.Waldon and pOO1)061)apse posed Moeda
Please na**the testi loceties ot the proposed trench and its purpose tiochade a description of what is tar in to
be taid to proposed tree&(ri;pipesindtk does etc..)Please use reverse skit it additional teem Is needed.
11151-akk CLAi O izet;(- tAljvN
Insunafte Certificate
S2'518114
Name and Contact Informatkm et Inaufer,
I Segte,cktk, tAS.
Pt * time now
DItt Sete "
106?1762572.
Name of Competent Penns fee dratted by (Ma 7,021:
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Maastottuarna Testing Llama P HE. o Limn cruktt I C?
2-4
Expiration .
EY SIGNING MEI FORM. Tilt APPUCANT,OWNER,AND EXCAYATOII ALL ACILNOWLEDGE AND CIC*Tifl'
THAT THEY ARE FAMILIAR WTI'I ,OR.BEFORECo a a Of ma WORK, BECOME FAMILIAR
V ALL LAWSAND*EGUULATIW APPLICABLE TO WO PROPOSED, C DING OSHA .
earl . � CTMl* 7.A* it 11., AND ANi APPUC - MMUNSCIIPAL. ORDISIANCES,
REGULATIONS AND THEY COVENANT AND AGREETHAT ALL WORK DONE UNDERT1'AEI?FOR
SUCH WORE WILL COMPLY THEREWITH IN ALL R AND VITTII THE CONDTTITITYS SET FORTE
BELOWW,
THE UNDT IGNED OWNER AUTHORIM TUX AppLicAmi TO APPLY FOR THE PERMIT AND THE
EXCAVATDQ TI) UNT E&7ANCE SUCH WorDE ON THE PROPERTY or ERE OWNER, AND ALSO, FOR THE
DURATION OF CONSTRUCTION, AUTHORIZES NS DULY
ENTER UPON THE paorEary TO MiONKTOR AND &NIECE THE WORK
FOR CopareahiFFIt MITI THE
CONDITIONS ATTACKED HERETO AND THE LAWS AND BEGIILATRONS COVERHIG SUCH WORK.
TUE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REEKEUA
IS TEE MU tICIPALfTY FOR ANY AND ALL eons AND MOISES INCURRED BY THE'
MUNIALITY IN CONNECTION wry THE Ps ITT AND THE WORK colvimi
INCLUDING EiMIK/RCYNG ME t ^ OF STATE LAW AND CONDITIONSOp
PERMIT,INIVERTIOPS MADE TO ASSUME COMPLIANCE TORILYWMI,AND IKEASURIES TAKEN EY THE
NIUNICIPALITY TO ratyracrTHE PVIILIC WHERE ITIE APPLICAY4T flit APPLiCAnT OWNER OR EXCAVATOR HAS FAILED TO
DMPLY THEREWITH INCLUDING POLICE DETAILS
RY sY MUNICiPA . DEEMED
TER IRSIGNED APPLICANT,OWNIIII AND EXCAVATOR AGREE J N°TLY AND SEVERALLY TO
!IV'IIE MMNON,AND HOLD IIWIMMESII THE SIUNI+CIPALITY AND ALL OF in AGENTS
ANY ALL I.IABLUTY,CAUSES OR A N,a L ING ARO TCINPII.�AR N
OP ANY INJURY. DEATH OR OR DAMAGE TO ANY »s: M 4( G OUT
CONDUCTEDUNDERPERMIT. a i�r yEG ? WORE
APPLI SIGN RE Z 123
DATE 1
EXC VATOA I NATUT »iI IF III ^j
1
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
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