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HomeMy WebLinkAboutBLDTR-23-001302 mawJ- q/jz1r� 4 R�q TOWN OF �R�IOUTH �?• . ,?a BUILDING DEPARTMENT Permit Number 9)L.A) - 2.5 - ©; , r'r L iia 11-I6► Route 28, South 'Varntouth. NI: 02664 Date Issued b b ) V.,":"^f�Asti ' 508-398-2231 ext. 261 Fax 508-398-0836 Expiration Date ).0 RECEIVED TRENCH PERMIT SEP 12 2022 Pursuant to G.L. c.82A §1 and 520 CMR 7.00 et seq.(as ame, d d) BUILDING DEPARTMENT THIS PERMIT MUST BE FULLY COMPLI!rr,1)PRIOR TO CONSIDFRATI i,N3y Name of Applicant ` r Cy-Cc.N.J c-vC\ Phone -- Cell Street Address� C�e�x 5�� �n L\ - C-�Z. ©O�-‘.�5 City/Town MA I ZIP Name of Excavator(if different from applicant) Phone Cell Street Address City/Town MA ZIP Name of Owners)of Property C'�ev(Ce , _c ( Phone Cell Street Address �U.7C GT)- CO‘0^--1 (--\O CocA p,\e G\cuve.. VN ... City/Town MA i ZIP •\VM MbOVlr\ .. (..51,(CU'\ Other Contact 7-Permit Fee Received No( ) Yes( 1 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(eg:pipes/cahk lines etc..)Please use reverse side if additional space is needed. -eR\-k c-- Cmc ove, \)\-c)�., - Insurance Certificate#: G72, 0 w A\u _..-n773..1\ Name and Contact Information of Insurer: gMei v_L,h 7 %c\. I'Douo\�� `� 0,fie ,� 6() �5-VoZ0 Policy Expiration Date: 5 L t2 I'-G1,15 --- ____._. Dig Safe N: Z0-1,5 G`-2:2.-C^5 — Name of Competent Person(as defined by 520 CMR 7.02): W 1 of r- ._ � _ .- Mtkassdiusetts Has'ling License" License Grade Expiration Date: t' I CO 1 1-01 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 c. $2A, 520 CMR 7.40 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 Di 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 coNsntucnoN, AirrHowzas PEICSO S DULY APPODITED BY THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMTIY 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 PERMTT AND THE WORK CONDUCTED THEREUNDER, INCLUDING BITE NOT Lmrrup 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 DETAtt S 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 LIABILITY,CAUSES OR ACTION,COSTS,AND EXPENSES RESULTING FROM OR ARISING OUT OF ANY INJURY, DEATH, PASS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT. APPLICANT SIGNATURE DATE EXCAVATOR SIGNATURE(IF DIFFERENT) DATE OWNER'S N TUJRE OF DIFFERENT) DATE: 09.09.22 zit : ":x " rt 3n a� � 2 of