Loading...
HomeMy WebLinkAboutBLDT-23-3067 TOWN OF \ ARMOUTFcI $C7)T Z3- ai (o� • fY .� '_ © BUILDING DEPARTMENT Permit Number Ol • —y 1146 Route 28, South Yarmouth, MA 02664 Date Issued 508-398-2231 ext. 261 Fax 508-398-0836 ..I- _JJ Expiration Date RECEIVED J U L 14 2023 TRENCH PERMIT ant to G.L. c.82A §1 and 520 CMR 7.00 et seq.(as amended) UI BLDING DEPAR NT 'F}44S-"ERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant c etAC Cb Phone 8Cf"" 77'i 247 3f 14' Street Address 33 wAl4es Pa )60404 MA ZIP Circle; Name of Excavator(if different from applicant) Phone Cell Street Address City/Town MA ZIP Name of Owner(s)of Property r6 Ditti f Phone Cell —� stse•9?2-6e/6 3 Street Address jaw kr City/Town MA I ZIP 4XiA 41/nOu oh Craver 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. tLif/" of - aittra Avelinf Insurance Certificate#: CPA Igo 626 -3a Name and Contact Information of Insurer: 146 .� na a/ Afeo Aries allow lewoen e_ Policy Expiration Date: [ fadip Dig Safe#: ( 3?y0 piq Name of Competent Person(as defined by 520 CMR 7.02): G/il/iaAl £ uifief lof2 Massachusetts Hoisting License# /0..59523g License Grade: itc ' HE- Expiration Date: ' // 0 Rif 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. THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY ifiE 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 1•HE 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 OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT. APPLIC SI NATU DATE 0/aat77 E CAVATOR SIGNATURE(IF DIFFERENT) DATE O ER'S SIGNATURE(IF DIFFERENT) DATE: 7-5-23 • Fut latkfrolin --.Do ria►t writh Ii it tioq - rERM_1T AFPRU II:�Y = • t :�1p • utleuui Fix . . Date: • . PERMUTING AUTHORITY . • � .• • � . . CONDITIONS OF:APPROVA • 2 of 2 AGENCY CUSTOMER ID:ROBEBOU-01 MVERTENTES LOC#: 0 ►COR'O ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY License#1780862 NAMED INSURED Robert B Our Co.,Inc. HUB International New England 24 Great Western Road POLICY NUMBER - P.O.Box 1539 Harwich,MA 02645 SEE PAGE 1 CARRIER NAIC CODE SEE PAGE 1 SEE P 1 EFFECTIVE DATE:SEE PAGE 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance ***Additional Policies*** Contractors Pollution Carrier: Illinois Union NAIC#33667 Policy#CPYG27416676004 Term: 12/01/2021-12/01/2023 $2,000,000 Each Occ/$2,000,000 Aggregate- Motor Truck Cargo Acadia Insurance Co Policy#CIM518214918 term: 12/01/2022-12/01/2023 Limit$500,000 Per Conveyance Installation Floater Acadia Insurance Co Policy#CIM518214918 term:12/01/2022-12/01/2023 Limit$300,000 Per Jobsite Deductible$5,000 Professional Liability Ironshore Specialty Insurance Co Policy#DCP7BABOPF0003 term : 12/01/202212/01/2023 $2,000,000 Each Claim/$2,000,000 Aggregate ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ��..1) ROBEBOU-01 MVERTENTES ACOREY CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 4111e...------- 11/30/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.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 ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER License#1780862 CONTACT Catherine Lawrence NAME: HUB International New England PHONE FAX 222 Milliken Boulevard (A/C,No,Ext):(508)235-2207 (NC,No): Fall River,MA 02721 al IDAAss:catherine.lawrence@hubinternational.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Firemen's Insurance Company of Washington,D.C. 21784 INSURED INSURER B:Acadia Insurance Company 31325 Robert B Our Co.,Inc. INSURER C:Navigators Insurance Company 42307 24 Great Western Road P.O.Box 1539 INSURER D: Harwich,MA 02645 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED 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 IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD IMM/DD/YYYY1 IMM/DD/YYYYL A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR CPA1301428-32 12/1/2022 12/1/2023 DAMAGETORENicg 1,000,000 , X PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 20,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY X JECT X LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ X ANY AUTO MAA1301425-31 12/1/2022 12/1/2023 BODILY INJURY(Per person) $ OWNED SCHEDULED _ AUTOS ONLY AUTOSpp BODILY INJURY(Per accident) $ AUTOS ONLY AUUTOS ONLYY (Per accidentDAMAGE $ $ B X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 7,000,000 EXCESS LIAB CLAIMS-MADE CUA 5460543-12 12/1/2022 12/1/2023 AGGREGATE $ 7,000,000 DED RETENTION$ $ A WERS COMPENSATION AND EMPLO ERS'LIABILITY X STATUTEPER E ERH ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WPA0316767-23 1/1/2023 1/1/2024 1,000,000 OFFICER/MEMBER EXCLUDED? N N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C Commercial Umbrella GA22EXC8887101V 12/1/2022 12/1/2023 each occ/aggregate 9,000,000 B Equipment Floater CIM5182149-18 12/1/2022 12/1/2023 Each occ/aggregate 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re:Trenching Permit Certificate holder is named as additional insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE 91.9?ai I ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • • .N../ • • . • • • • ° ‘L. g ctl * g 137 q 0 g:g a z ti/tor 3 , g(, I: 43.` t 0 g 0*, • mk-) g • ?5z. •194 Ft, 44. , ro 0 •_ ,*N-te vz. ; a 1 • e• i'6.voit;116, 1• ••a4a•A 0 • 44•IN • • • • • • • • • • • I • • tga =fir v - x I p rn o r- C .a 1111 C0 al co.-. 1 co E y E ti 0 ....< go V 0 .