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HomeMy WebLinkAboutBLDTR-23-003560 r rn 44 le,e- / l�9 Id-a-- Si' TOWN OF YARMOUTH °'F ca) t, a BUILDING DEPARTMENT Permit Number C�f�7l�-?, _ "y 1146 Route 28,South Yarmouth, MA 0266�# �„ 5f)8-398-2231 ext. 1261 Fax 508-398-083b Date Issued Q 3 (p Expiration Date f�)L $ Oz6, $50.00 TRENCH PERMIT Pursuant to G.G. e. 82A 11 and 520 CMR 7.00 et seq.(as amended) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant O ,0'(:)...0-vvesJ fr\ci Phone p Ce Street Address "1 i Lt - 16 Irni ,�rVe ®g 6 t��p ( City/Town MA ZIP 0 are--7 S _ Name of Excavator tit different from applicant) Phone Cell Street Address City/fawn MA ZIP Nome of Ownerts)of Property M A m P Cell Street Address , 1 I ",tiax (7►�' a1 �-1 6 C,i�t(y/ own MA ZIP W . Uptrvyntrult v Other Contact I Permit Fee Received No C) 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 for is intended)to be laid in proposed trench(es;pipes/cable lines etc..)Please use reverse side it additional space is needed. 1,(1,trx„,,Q, 4. .,‘ ,.v‘ ,,t _, faiA,Q,Toby„,, LM/ ,P._t0ili, (J� \ :31...ert,u3s, i 1 Insurance Certificate If: Nance end Contort tnformadnn of insurer C. N PS c) MA NOtritt& Polley Expiration Date: 1 a-a y- a Ms Sale f! a©da J o a® / ECEIVED I of Competent Percoa ins defined by$20 C'Sil 1.02): i I Naar h 1 Ii DEC 2 8 2022 6UfLDINC; DEPARTBy MENT tof2 r.- , ia�� bi Massachusetts Hoisting License B E {Q l 1 1 20 , License Grades _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, G.L. e. SZA, 5211 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 WORT[ 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 DEFEND, INDEMNIFY,AND HOW 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 hit-ok -g..ft D DATE /oZ,�o�7 I EXCAVATOR SIGNATURE(IF DIFFERENT) DATE OWNER'S SIGNATURE{IF DIFFERENT) " aoutef2Api.3 DATE: Z 1cTl3 aa Q roe obtrowe - I11 M r*irl fhb IT Applkaase fee ItAt. 2 of 2