HomeMy WebLinkAboutBLDT-23-2078 Ya TOWN OF YARMOUTH
'•O R4s BUILDING Permit Numbe���7 Z3- �7g
JDEPARTMENT
( 'y C 1146 Route 28,South Yarmouth, MA 02664
� cue(' 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
Expiration Date
$50.00
TRENCH PERMIT
Pursuant to G.L.c.82A I1 and 528 CMR 7.00 et seq.(as amended)
THIS PLRMTT MUST 8E FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applies*r, Cell
Street Address
.U ZOn S5C
4)Ca:cat
City/Town MA ZIP
°o(e \-c\r-Ne CAtoLAL-1
Name of Excavator(ifdiferent Troupe applicant Phone Ceo
Street Address
City/Town MA ZIP
Name of Chyme's,of Property - +Phone Cell
Y'v
scree' ( (-5()cs 3G0—
City/Town MA ZIP
Other Contact I Permit Fes Received Net ) Yes(
i>tserlption,location and purpose of proposed trench:
Please describe the exact location of the proposed trench and its purpose Qnehrde a deseriptlon of what is(or is intended)to
be lair be proposed trench(ens;pipes/cable lines etc..)Please use men*side R additional space is needed.
TGICA:\'') CNA\C,C\ qUe—
law erect Certificate Its --5 0 ?1
Name and Contact fnfornutlon of Insurer:
M} \ .c\-\- \(Y,c,1C\5t�(c,r� C50�ZO,�O 11
Pocky£spkstion Date:5 MZ.I un_LA
Dig sa r: 7-01,M.32DL-\C)55
Hems of Competent Person tas defined by 529 CMit 742I:
C�\S-\ems@- v.rr5e xcc- vim.. c n 4C0c
Iof2
1.
weedHaisiiii Liman n 1 VAC. 1A5-
.
Lkenso Grade:
'mikados Dote (S 1 CO I 7-07-
THAT THEY ARE FAMILIAR BY SIGNING TIES FORM,THE APPLICANT,OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
TALL LAWS AND REGULATION!WITH,
OR,BEFORE COMMENCEMENT OF THE WO FAMILIAR
APPUCABLE TO WORK PROPOSED.INCLUDING
DIG OSHA
a PIA, STS CMR Me d seq., AND ANY APPLICABLE MUNCIPAL °ROMAN
BY-LAWS AND
REGULATION AND TREY COVENANT AND AGREE THAT ALL WORE DONE UNDER THE PERMIT ISSUED
SUCH WORE WILL COMPLY THEREWITH IN ALL R�ECI S AND W1Tp FOR
BELOW. ? CONDITIONS Miff FORTH
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WORK PERTY OF THE _ FOR
DURATION OF CONSTRUCTION,�AUTHORIZES PERSONS� AND 'T � � BY 7'HE ANDAL11Y TO
DURA UPONN WORK FOR
THE
CONDITIONS commaikary ATTACHED macro AND THE LAWS AND REGULATIONS GOVERINC SUCH Wan.
WTTR THE
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND
SEVERALLY
' REIMBURSE THE MtNICIPALTTY FOR ANY AND ALL COSTS AND E INCURRED BY THEE
MUNICIPALITY IN CONNECTION WITH TUM PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUMNG TMS mum INSPECTIONS MADE TO ASSURE COMPLIANCE Tanegwrrk AND SUP NOT LIMITED TO ENFORCING THE REQUIREMENTS OIT STATE LAW AND CONDEMNS OF
COMPLY
NLCIPALITY T O PROTECT THE PUBLIC WHERE MEASURES HASTAKEN IL 1ET
THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL T OWNER�Sv ES FAILED TO
NECESSARY BY THE MUNICIPALITY
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE
AND INDENDfiY,AND HOLD HARMLESS THE MUNICEAury AND ALL OF JOINTLY SEVERALLY TO MEND.
ANY AND ALL LIABILITY,CAS OR ACTION,COSTS,AND EXPENSES RESULTINGAND EMPLOYEES FROM
M OR ARISING OUT
OF ANY
CON CTED P .DEATH, LOSS. OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
APPLICANT SIGN RE
DATEk5
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
i ,t e d
4 2 i y DA •
LZ_ _____3 I
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