HomeMy WebLinkAboutBLDT-23-2080 *;y4:e TOWN OF YARMOUTH
4:4 BUILDING DEPARTMENT Permit Number • -Z3
( ' ''is. y 1146 Route 28,South Yarmouth,MA 02664 Re
:� *T ,v;t 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
Expiration Date
$50.00
TRENCH PERMIT
Pursuant to G.L.c.82A 11 and 520 CMR 7.00 et seq.(as amended)
THIS PRRMIT MUST RE FULLY COMPLETED PRIOR TO CONSIDRRATlpN
Naaat of Applicant a p,
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Street Addrees
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to �07(0
City/Town MA ZIP
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Nave et Excavator tit different from app t1 Phone
Ced
Street Address
City/Town ZIP
iiminimomm
Name of Owneris►of PPsperty Phone
Address
Celt
Sae• 774 • GvGostreet
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City/To MA Z
\des" IP
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Other Contact lPrrmit Fee Received No( 1 Yes
Description.location and purpose ot prepaid treads
Please descram the exact location ot the proposed trench and its
purpose be laid In proposed trench teat pipes/cableSaes etc.)Please use taddhlmad descripftu Is whated is(or is intended)to
/ v e space Is aaeded.
Sig �i To sk l
P AUG 09 2023
BUILDING DEPARTM•NT
, Ins Ce Ft By: -_
Neme and Contact intorn ation of insurer:U
ZCJ't'rk gelef a4
don Date:
Dies Sate F:
Name of Competent Pens*i es defined by 520 CMR%.01 t:
Cage c,er 1 Ga,„
1 of 2
•
M.essdaretts HoisOs#I.Noense# J /C/3
Lkeese Grader l' Espicdios Date (3 4/4 1 fie.]
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,
IONS,
G.L. e. 12A, 521 CMR 7.IS at set., 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 WTTH THE CONDLTIONS SET FORTH
BELOW.
THE UNDERSIGNED OWNER AUTHORIZES THE APPI JANT 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, AVTHORTIZs PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WTTH 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 ANT AND ALL COSTS AND EXPENSES INCURRED IT THE
MUNICIPALITY IN CONNECTION WITS THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT LIMITED TO ENFORCING Till RBQUIREMBNIS OF STATE LAW AND CONDITIONS OF
TINS 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 MUNICIPAI.TTY.
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 MENSES 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
TE A
EXCAVATOR SIGNATURE tIF DIFFERENT)
DATE
OWNER'S SIGN ( IFFERENT)
DATINS,/-
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posami
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