HomeMy WebLinkAboutBLDTR-23-001689 hl Li lett( clizqlaz_
..... .........
4...-717k.t.... TOWN OF YARMOUTH
(.%,4.*4. 10 BUILDING DEPARTMENT Permit Number 6/z7-e S3--
./ 4,01414 t 1146 Route 28,South Yarmouth,MA 02664
508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued 0 4 11.0 S-67
Expiration Date C,I(A4--)35o5
$50.00
TRENCH PERMIT
Pursuant to G.L.e. 82A f I and 520 CM*7.00 et seq.(as amended)
TIDS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
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Notre al Appikaint 6 a et i .ki,„ IAA.. Phone Cat
Straw Address 568' till-0t,c3
. 1..t1 g.6,14, r‘o
City/Town MA ZIP
soalckuj,6,, me,. 0/ Lt,
Neon of Excavator if different-6430 applicant) Photo Cell
Street Address
cotvroens MA ZIP
. .... ._
Newest of Oenerts)et Property Fraftat bron601/47, Pfienst Cell
Street Addren
31 Litt,do.. (( ad
,Cheroots MA T ZIP
5. 1 01/4(moviit.
,
Other Contact I Peron Fee limed No i ) Yee t i
Deseription localise and purpose oil proposed trench:
Please deenthe the'SAKI location tether proposed trench sod its pttirpOSt(include a description at what is tor ta intended)to
be toed to proposed trench teg;piparkahle Ran etc..)Phase use menet mid*it additional'peer is needed.
11151-6.tt&ii6e O( Slif;(-• 51641P1
RECEIVED
SEP 2122
insurance Certificate Or
21 S2, BUILDING DEPARTMENT
StUrt
Notre*and Canted ittinneattno of ineurer:
SeAtAtt, AS.
_Policy flteiratinn Mew si I i 2e4 —'— , '''' ----- :
1 Diligsfit* 2012740c114rt
, Nairn or Competent Penes o as defined by SU t MLR TAU):
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SY SIGNING Tins *OR(, THE APPLICANT,OWNER,AND EXCAVATOR ALL ACI NOWId+.DGE AND CERMET
TLLAT THEY ARE FAME WITU,OR,REFORE COMMENCDIElvT OF THE WORK,
WITI ,ALL LAWS AND EEGULATION3 APLCARL.E TfT WORK WILLDING LIIECOM$FA14LILIAR
G Ems► T2* CMR 7.IS +�t srr „ AND ANY APPLICABLE MUNICIPAL ORDINANCES, � N
RRGULA 'I AND THEY COVENANT A►1' AGREE T TA WORE DONE m1 E' BY-LAWS FOR
SUCH WORE WILL COMPLY THEREWITH IN ALL RESPECTS AND WITHI tJRDRTR
BELOW. THECONDTTIONII 'T
THE UNDERSIGNED OWNER AUTHORS THE Arturo? TO APPLY MR THE rimer AND THE
SXCAVATOR TO UNDERTAKE 9UC'IL WORK ON THE PROPERTY OF THE O
DURATION (�' CONI!�'RiJC"TLCIN, ALIT OWNER, AND ALSO,
ENTER UPON THE TO MONITOR AND ACT T� Won FORyarnAPPOINTED BY THE 71E
CONDITIMIS ATTACHED AND THE LAWS AND
COVERING RUCIL WORK.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REIMBURSE THE MUNICIPALITY 149111 ANT AND ALL COEN AND
VOWS= THE
MUNICIPALITY IN CONNECTION WITH THIS roma AND.TUE WORK CONDU INCURRED BYCTED
lNC"LUDPIC,RUT NOT LIMITED TO ENFORCINGLEUI RAINTIREMENIE OF STATE LAW AND toponym Or
THIS PERMIT,ACTIONS MADE TO ASSUME COI LPLLANCE
THEIRECWITIL MUNICIPALITY TO PROTECTTHE PUBLIC WHERE,THE APPLICANT AND l OR 1EICC t CAYAI T AS FALI.ETHE
#TO
BYCOMPLY INCLUDING POLICE DETAILS AND Cat ES HAS
NECRA1tY BY THE MUNICIPALITY. DEEMED
TIIIt UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND
INDEF*1R C,AND HOLD IIARMLI THE MIINICIPALITY AND ALL OF ITS AAt,LL ` OFFEND,
'Rest
ANY AND ALL LIABILITY,CAUSES OR ACTION,C( ,ANDIMMO ANDRO on ARISINGOUT
o ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON O RESULTING 1W ORW
CONDUCTED UNDER TIM PERMIT. DURINGTHE wen
APPLI SIG RE1 U Z I ZZ,
DATE (FAA'VIZ
EXC YATOR LGNATURE(IF'DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
-4.1.1111111111
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