HomeMy WebLinkAboutBLDT-23-2091 TOWN OF YARMOUTH
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° BUILDING DEPARTMENT Permit Numberl3CD7- ; 3--aCei
: .'7,g 1146 Route 28,South Yarmouth, MA 02664
Y 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
Expiration Date
$50.00
TRENCH PERMIT RECEIVED
Pursuant to C.L.c. 82A 11 and 520 CMR 7.00 et seq.(as amen )
THIS PIDLMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATIO AUG 2 8 2023
Nam of Applicant (C///�►�/,/� /1 J(''�y// ]a TO Pions_ GI BUILDING utrr+F2'MENT
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Name of Excavator Of different from applicant) Phone Cell
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Description,locative and purpose of proposed trench:
Please describe the exact location of the proposed trench and its purpose fInelude4deser40oa it wo..::,:.r is intenaeo,
be laid in proposed trench(ea:pipes/caMe lines etc..)Please use reverse side if additional space is needed.
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insurance Certificate r: I - ) 00 CEO Od .aQ 1 - g- oz- i4
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`tame of Competent Person t es defined by 520 C'MA 742):
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DocuSign Envelope ID:AEC8CB6D-8107-4B57-960A-E3500CD3E625
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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
WTTH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATE„
G.L. e. *2*, 520 CMS 700 e1 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 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, AUTHORI?ES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND DISPECT 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 CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT WAITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDi'TLONS OF
THIS PERMIT,INSPECTIQl4 MADE TO ASSURE COMPLIANCE TH REVI TTA,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 THR 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 EXPENDES 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
AX—L*''' DATE &'2Z3
EXCAVATOR SIGNATURE tiF DIP!i RENT)
DATE
DocuSigned by:
'S SIGNATURE(IF DIFFERENT)
' 8J28/2023
8B794888131794C5... DATE:
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