HomeMy WebLinkAboutBLDTR-23-001301 = g, TOWN OF YARMOUTH met It"— q l/z/ '
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' 440 't. BUILDING DEPARTMENT Permit Number 13LDTr _z3
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�� /R MA 02664
of .oy 1146 Route 28. South Yarmouth,
�' *,,,y•'.�,._ 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued 00130 I
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Expiration Date O )3.7
$50.00
TRENCH PERMIT R E D E Y E D
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as e dea-
f
0 9 2022
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERA N_
BUILDING DEPARTMF m
Name otApplicantailci, nusravi, PhoneJr, Cel By
Street Adidrevs?b goK 5 ___.3c-.) Nck.w5L,)6 ie.4 oEy 18 -
it
Cityfrown MA ZIP
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Name of E for(if different from applicant) Phone Cell
Street Ad4O'l VI cl urk-
4(65 iNie)\-1 C'Yrn OL i_ j Ltd 1 - --1.o3.34
City/Town MA ZIP
\ki5i--'ie.tratotktiA 0)-421 ?)
Name of Ownerts)of
Property Phone Cell
Street Address '1 ail. Si1M fW011�
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City/Town MA I ZIP
�t5- AMAv�- I 0 )4'13
Other Contact I 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(es;pipes/able lines etc..)Please use reverse side If additlond apace is needed.
6(21)11.—C-- •
insurance Certificate M: vi rt'J{ ,p
`lame and Contact information of Insurer:
RCX-V-CS L1 J \\)/ k1Y fie. , e ePC ( ) -19 t_.
Policy E,piratk:n Date: IO 5 20 L'
Dig Safe0: I ,f
02 - 3(00 . Re43O
'tame of Competent Person t as definedJ by 52D('SIR 1.O2):
.,1 G t t, (- t,t(LiL,
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ltEtinacituatits Hoisting License 0 t: " �? 1 L)
Items Grade: a C?i5�►Y1 ' �Gj 1'nee,( 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 WORE,WILL BECOME FAMILIAR
WITH.ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS.
G.L. e. 07A, 520 CMR 7.00 et se*. AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND
REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORE DONE UNDER THE PERMIT ISSUED FOR
SUCH WORK WILL COMPLY TIIEI?EWTTH IN ALL RESPECTS AND WTTH 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 INSFECT THE WORK FOR CONFORMITY WTTR THE
CONDMONS ATTACHED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH WORJL
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 or
THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURE TAKEN BY THE
MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO
COMPLY TITEREWTTU 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 IT9 AGENTS AND EMPLOYS FROM
ANY AND ALL LIABILITY.CAUSES OR ACTION, COSTS, AND EXPENSES RESULTING FROM OR AR/SING OUT
Or ANY INJURY, DEATH. LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGN�ATURE
�L�• yVli t a v�Gt_K— DATE
EXCAVATOR SIGNATURE(UP DIFFERENT)
w/ 11&� - DATE
t NER SI A CURE t IF D
DATE: ` ICP I 7c;r1-7,
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