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HomeMy WebLinkAboutBLDTR-23-000875 /8i-7+1 \ TOWN OF ti'AR1IOl'TH 9L1) 7�- 3-• 0067S. Permit Number �,�7 j � �p BUILDING DEP.�RT�IENT ' O ) 1146 Route 28. South Yarmouth. NIA 02664 ** r "jw 508-398-2231 ext. 261 Fax 508-308-0836 Date Issued Expiration Date TRENCH PERMIT Pursuant to G.L.c.82A §1 and 520 CMR 7.00 et seq.(as amended) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant j "v a p' id Phone Cell Street Address 3 fa,t4 ,C-�ro u I,cQ 1 C J r. ,22 -,?,7 City/Town MA I ZIP N, ,,., pcil- I CD(O75 Naaiof Excavator(i ifferent from applicant) Phone Cell Street Address City/Town MA ZIP I Name of Owner(s)of Property ,p I.&cI I I NOVA/ b Phone Cell Street Address507 Denrir > g ,�,,f K► Cityffown MA i ZIP Other Contact I Permit Fee Received No( 1 Yes( ) 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;pipeslcable lines etc..)Please use reverse side if additional space is needed. h env gel 14 L RECEIVED I La_m_iG 17 2022 BUILDING DEPARTMENT ©y. G - Insurance Certificate M: — Name and Contact Information of Insurer: I ' ,%6L\\ ' '►} L IG I 65w CI CO ' Policy Expiration Date: ? i , a, G — Dig Safe 0: saga 3o0 Alin Name of Competent Person t as defined by 520 MR 7.e2>: I oft Massaebusetts Hoisting Limns# 9 IBC vv k' License Grade: - 69603 _Expiration Dine: 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 WTIB,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS, G.L. a SLI, 520 CMR lie 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 WITH THE CONDITIONS SET FORTH BELOW. THE UNDERSIGNS 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 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 CONNECTKIN WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER, INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF THIS PERMIT,INSPECTIONS S 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 EMPLOYEES 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 ATE 5 '` f 2",, EXCAVATOR SIGNATURE ddF RENT) DATE OWNER'S SIGNATURE(IF DIFFERENT) (1` ?491/7Lk-DATE: 7ZU2-Z Far wawa— _w+IMR Sithatedis= ' £byes t Y 1 Felt . 2 of 2 ACORD CERTIFICATE OF LIABILITY INSURANCE °" ,"'N°ONT o"'' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDf11ONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,Subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT RogersGray, Inc.-Kingston Branch Nam` 63 Smith Lane PHONE Exty 508-746-3311 .Nek 877-816-2156 Kingston MA 02364 : maliarogersgray.com INSURERS)AFFORDING COVERAGE NAIC I INFRA:West American Insurance Company 44393 INSURED REIDSLA.O1 INSURER B:Arbella Protection Insurance Company,Inc. 41360 Reid&Laurence Ellis dba Ellis Brothers Construction 23 Enterprise Rd,P.O.Box 59 INSURER C:Associated Employers Insurance Company 11104 Yarmouthport MA 02675 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2114965942 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONORION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. i POUCY EXP LT3RR TYPE OF INSURANCE I NND POLICY NI ER ANIL SUS* (MMlf)� 1fYY7n LIMITS A X COMMERCIAL GENERAL UASIUTY BKW5837-I201 311/2021 3/1/2022 HRENTED EscE $1,000,000 DAMAGE CLAIMS.MADE X OCCUR PREMISES(Ea occurrence) $100,000 MED EXP(My one person) $15,000 PERSONAL&ADV INJURY S 1,000,000 GENt AGGREGATE UMR APPLIES PER: GENERA,AGGREGATE $2,000,000 X POLICY LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ B AUTOMOBILE UABILITY 1020002807 6/9/2021 6/9/2022 PETABINED)SINGLE LMgIT $ ANY AUTO BODILY INJURY(Per person) $250,000 Owns° -SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $500,000 X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Pet occident) $100,000 $ UMBRELLALIAB OCCUR — EACH OCCURRENCE $ — EXCESS LAB CLAMS-MADE AGGREGATE $ DED RETENTION$ C WORKERS COMPENSATION WCC-500-5000706-2021A 12/3/2021 12/3/2022 $ AND EMPLOYERS'UABIUTY Y/N ATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMSEREXCLUDED? {-IN I A E L EACH ACCIDENT $100,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $100,000 lives,de be under DESCRIP ION OF OPERATIONS below E.L.DISEASE-POLICY UNIT $500.000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLEs(ACORD 101,Additional Remarks Schedule,may be attached If more space Is requbed) Certificate holder is listed as additional insured under General Liability for on-going operations when required by written contract or agreement CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WIWI THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth MA 02664 A REPRE VATIT 70444.4.............. / IVE 01988-2015 ACORD CORPORATION. All tights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD , . . - ., I, f i , / 1 Airs, Commonwealth of Massachusetts / / . VI - Division of Professional Licensure . .• . . -- Hrkim/Agtifilirer - --.- . _ . HE-028673 0 - -4_ Oto, ires:12/30/2022 , g 1 -. LAI.OtENCE 12ELLIS-13 ----*.F .. _ 8 NORTH ST:2, DEM418 PORL)AA 82-111-84f . J1S:sq:11 . , Commissioner ir4!a K.•(e&nj.ri...... . 4. - . . , . A ".....'"."*--'-"" ".'''.".'"'"'.......---'""".."....""'"."'.."'""'""'"*"'"•.--.......................N ReStrieted*O. ii°63thIg algineer fie-7A..,excavtors. DIG sApE n... as In case —.Center• ' Contact ople:. °f accition -‘888)344-7233 Mt can' 7)7274200 ' (608)8204444 or visit, -....47424410wriplieesi / ..... - , ( / • -- ...... . _