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HomeMy WebLinkAboutBLDT-23-2068 r"�" TOWN OF .aR11(�t i'I tl o�' '�'4 Permit Nnmbe�r '��� � off° .t- • k' p Rtitt.DtNG DEPARTMENT of t i«, t l46 Route 28.South Yarmouth. MA 02664 Date54 Issued �,:---,-, 5u*-398-223i ext. 261 Fax 508-398-O836 Expiration Date TRENCH PERMIT Pursuant to G.L.c. 82A §ll and 520 CMR 7.00 et seq.(as amended) THIS PERMIT MUST RE FULLY COMPLETED PRIOR TO CONSIDERATION Nis**of Apptieen* Terry Walker Excavation Inc Pk*"508-255-8785 Celt 508-509-5870 Sweet"dm" PO BOX 115 City/rown 1 MA f WEST HARWICH i_ 02671 L — Name of Excarator(ifdifferent from applicant) Phone Cell Street Address Same r City/Town MA ZIP Name of Owners)of Property Phone Cell Thomas McCafferty street Address 57 Driving Tee Circle City/Teem "-MA I ZIP S. Yarmouth 02664 Other Contact_ Pit Fte Received No( ) Yes( ) Pleaseptes Description,b location and purplocation of proposedpo d trench and its purpose(include a description of what is(or is intended)to Please describe the exact iatation of the proposed be hid in proposed trench(es;pipeslcabk liars etc..)Please use reverse side if additional space is needed. AS PER PLAN TO INSTALL TITLE V - EXCAVATION FOR NEW ADDITION insurance Certificate I: PPP, 3111 - I lAR WC:GSCK)5f11714-2022A-WORKFRS COMP M1T17.3.ZL=AAUTO Name and Contact information of Insurer: McShea Insurance Agency - Joe © 508-420-9011 Policy Expiration lbw -0$4 3 liab 02/07/24 WC &Auto Dig Safe t" 2023-2813291 ---A I Name of Competent Person ins defined by 529 CMR 7A2i: RECEIVED Terry S. Walker, President UL 14 2023 it J b I- \ -7-'elfel s3,/A lk.e.,- 6 f,9,,,,J-,,,/. 6,,,,n _v �UiLDiNC, f�L=PARS �1;_�i I 1 of 2 �� _— ---- - I Massichwens tm isti.g Lcense# HE 041513 License Grade: Grade 2A Rxpirsrtion Date. 05/15/24 BY SIGNING THIS FORM,THE APPLICANT,OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AM)CERTIFY THAT THEY ARE FAMILIAR WTT'H,OR,BEFORE COMMENCEMENT OF THE WORK,WILL BECOME FAMILIAR WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS, G.L. c. S2A, 520 CMA 7.08 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 COVERING 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 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 AGREE JOINTLY AND SEVERALLY TO DEMO. 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. APPLICANT SIGNATURE�� 6r0/e/. Thee- DATE 7-13-23 . Wa►ker, President EXCAVATOR SIGNATURE(IF DIFFERENT) DATE OWNER' SIGNATURE(IF DIFFERENT) Q�lrl ' DATE: 7-13-23 Thomas McCafferty "'. .- . -_ . .---, - . 141/11111690110k71.1itiftbrilleisksibrAL- '''''---- - - ' •7 2 of