HomeMy WebLinkAboutBLDT-23-2076- 77'
' 2TOWN OF YA. UU'l'tl
Y BUILDING DEPARTMENT Permit Number & 67 Z3-20-7,6
1146 Route 28,South Yarmouth,MA 0 664
(000.44)
s s, - ext. Y a e. s s r► Date Issued
Q
Expiration Date
AUG $50.00
03 2023
TRENCH PERMIT
ByB U I L D I N G rs G.L. c.82A 11 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applkant poo G coocAltin
.. e C.o b C Ser "ic,e. '� ~C VS-a 5 Ceti
Street Mdrew
Q at Email Address:04 opholztAx41,SepaciCeyediktri
city/Town MA ZIP
Name or Excavator of different from applicant) Phooc Cell
Street Address
Email Address:
City/Town- MA ZIP
Naane of Ownerts)of Property Phone Cell
Street e\a. i,p17'^ 1 '' )t
Address
oa In tr'.cf `-f l Email Address:
Cly own MA ZIP
Gc h C 7-D
Other Contact I Permit Fee Reeeivcd Not ) Yes( )
Description,location and purpose of proposed trench: •
Please describe the exact ioc*tion of the proposed trench sad its purpose(include a description of what is for is inteaded)to
be laid in proposed trench(eg,pipesfeable lids etc..)Please use reverse side if additional space is needed.
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i Insurance Certificate Of
I Nance and Contact Information of Insurer: CtliAnik 4t. pVMe4 i -t'1SS1,3t`t
1 PO ( of 1X \ i cnR oat c
Policy Expiration Date:
Dig SateP: .
t ap _ MGav, .
Name of Competent Person t ai defined by S20(MR 1,02k:
' PC►l\ t&c rr
1 of
•
„ •
0'44 $•-•
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Name of Competent Person(as domed by 520 CMR 7.02):
9civ1 "&n
Massachusetts Hoisting License# 0c649C17
License Grade: C., C4,;)A Expiration Date: 5/V 1 j, '5
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,
S,:
G.L. c. 82A, 520 C VIR 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 MTH 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 GOVERING SUCH WORK.
'ice 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 WmI 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 HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOY=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 7/c-/2 3
EXCAVATOR SIGNATURE(IF DIFFERENT)
T)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
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