HomeMy WebLinkAboutBLDTR-23-002622 md4 Poe_ /irn-
- ,„vs.Yq� TOWN OF 1'AR\IOLITH
I o Bt11LDINC DEP.aRT�tENT Permit Number L311) 772-, 3—
o _ • , ,Q,�yl 11-16 Route 28, South Yarmouth, NIA ii2664 Date Issued �� 2Z
Y h int 5'I.y4 508-398-2231 ext. 261 Fax 508-39 -0836
. Expiration Date l7 l /1' h(Q
TRENCH PERMIT
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant Phone Cell
Dig It Construction LLC 508-367-2256
Street Address 508-432-1635
22 Diamonds path / PO box 268
City/Town MA ZIP
South Dennis 02660
Name of Excavator(if different from applicant) Phone Cell
Street Address
City/Town -MA ZIP
f Owne (s)of PropertyPhone Cell
-Name / A/ca &:te
Street Address 6 C`7`'j 1 t✓1 a. -7
Cct,I i o \ 1,
City/Town MA I ZIP
9cAr o .-K 09\ ?3
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; pipesfcable lines etc..)Please use reverse side if additional space is needed.
I cepA-ti C-.. de_- C-
RECEIVED
Insurance Certificate#: NOV 10 20
22]
ZDNJ017376 _DING__
DEPARTME
Name and Contact Information of insurer: ul3 By _ILDEPARTMENT
Eastern states Insurance - 781-642-9000 -_._._____
' Policy Expiration Date: 5/18/23
1DgSafe : 90g^ " 1(/ Lib
Name of Competent Person Ias defineddtby 520 CMR 7.02):
,Kerry Sullivan
1
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Massachusetts Hoisting License# HE-153873
H E-2A 2/24/24
License Grade: _ Expiration Date:
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,
GI,. 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 T'IIE 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 DEl+"ttND,
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
DATE AC)/9Q
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNE SI TURE(W DIFFERENT)
DATE:
TE
• I nr CIl ft o n rrne- Ilia not write in this •
PERMIT APPROVEDH S, Apok Lion l ie •
PERMTTTI AUTHORITY
Cl).'KDIT7l7t7i or APPROVAL _e .�.
•
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