HomeMy WebLinkAboutBLDTR-23-005933 e''''" TOW Or YA,MUU'I tl
y • :ft. �' BUSING DEPARTMENT Permit Number i3U) 7h —
1146 Route I8,South Yarmouth,MA 02664 ti 4l ` 5c► 9 -�1 ,1 1 Fax .3 a Date Issued 0Z`�_ -6�)S 9 zLi
Expiration Date Ci1C.4
$50.00
TRENCH PERMIT [ R_.E 'C E I ' c D
Pursuant to G.L.e.82A 1 and 520 CMR 7.00 et seq.(as amended)1 I
Tuts PERMIT muff BE FILLY COMPLETED PRIOR TO CONSIDERATION APR 26 2023
NioneetApplies*z � 'n iPh". Cell BUILDING C' N EPARTMET
f
Street
50 Pilt ail,. Email Address:t 4..\04 10 ,!Cat MC tiit.Cro
l mm►o (Nato?)
Nacre ofExcavato r iif ati'Tereait front scant) Phone Cell
Street Address
Email Address:
City town MA ZIP
Name of°weans)of Property fr a,ste- S' Cell
Street Address
,673 ,!arfr45e, i r1e 1,Q4/: Email Address:
Cltyftown MA ZIP
Cu. y�e-Ase'®te 0267,
Cither,Contset 1 Permit Fes Received No i ) Yes( I
bleeder and purpose of proposed tretcht
Please describe the exact location of the proposed trench and its purpose{include a description at what is for u tnteuded)to
be laid in proposed.trench leg ptpedcabie Date ete..)Mean use reverse side itaddit[onel space Is needed.
. tis -i. „...e...-.e-' S-e IG /109 / —'e7" o-F ,•%7.-z,„es&..
Insurance Certificate itt
I 1P.X)e)Z1409 4 a9
New and Contact Information of Insurer; OcuAnct4t. Cy Mat i "Mcsiurofre
I PO OA IC Q Wiontilg .cfA C to41
: Polley Expiration Date: /1ala '.
*fame of Competent Person taa defined by 520 C'M&7.02):
' - 90,0 i1&n
Iof2
Name of Competent Person(as defined by 520 avra 7i4
-!`-0.0 MorNAC`1
Massachusetts"Waft r.ice»e# 006494` 7
License Grade: \C..' 3,'.Ji #, Expiration Date: '1t?
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. 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 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.
TILE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
0.URSE THE MUNICIPAJ 1TY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE
MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUeFED 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 AGM 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 INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DUNG THE WORK
CONDUCTED UNDER THIS PE MIT.
APPLICANT SIGNATURE
DATE 47 z
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:.
3