HomeMy WebLinkAboutBLDTR-23-002023 TOWN OF YARMOUTH a ' /r. f•
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• ot - BUILDING DEPARTMENT Permit Number L1�-1Z, -�3
,g 5 1146 Route 28,South Yarmouth, MA 02664
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wviv 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued ,002, 2 3
Expiration Date C Gfir 2 50 23
$50.00
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 CONSIDFJtATION
Name of Applicant 4 K_Gvr1 e(C_'Ql/+i►'1Cj f.�L Phone Cell
Street Addrets J 5-6 U 3 Z --5
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City/Town MA ZIP
arinis PnR 02...1440
Nam of Excavator(if different from applicant) Phone ciii
Street Address Sc �
City/Town MA ZIP
Name of Owneris)of Property ia)ucj I tt + e�„.,r\ Phone Cell
Street Address
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City/Town MA ZIP
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Other Contact l Permit Fee Received No(L ) Yes( )
Description,location and purpose of proposed trench:
Please describe the exact)onuses of the proposed trench and its purpose(include a descriptlea of what Is(or is intended)to
be laid in proposed trench le`:plpeakabie Noes etc..)Please use reverse side if additional space Is needed.
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BUILDING UEP
NOV 0 9 2022
By. ARTMENT
Insurance CertiRcate Os
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Name and Contact Information of insurer.
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Poi1tY E.piration Dor.
Dig Safe N: 2-0 Z-2- LAI 2-
Name of Competent Persoa(as defined by 520(SIR 742):
SOLY171 SACatY W)
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Massachusetts Hoisting License it — L- 3 O(y O
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Llsense Grade: 1 T/ Expiration Date: // /�D.7 3 _
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. e. 32A, S20 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 TIlE
DURATION Off CONSTRUCTION, AUTHORIT.BS 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 TN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF
MS PERMIT,INSPECTION$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 DEFEND,
INDEMNIFY, AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM
ANY AND ALL LLABI ITV,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 /1/ /?-vl
EXCAVATOR SIGNATURE OF DIFFERENT)
DATE
OW E SIGNATURE 1IF DIFFERENT)
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