HomeMy WebLinkAboutBLDT-23-2100 TOWN OF YARIMIOUTH
4 o BUILDING DEPARTMENT Permit Number gz_D 7-Z3--4o
c 1146 Route 28, South Yarmouth, MA 02664
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Y\MATTA M C,[; 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
Expiration Date
$50.00
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 AppJicatd Phone Cell
Street Addreat?G GOK 7 1 1�l v-Aton 5bg 31l L�its
Citity/Town MA ZIP
1/ LlVj i,< at '1 E AVfl C1mitCH-f1.G1(12m�P F VT Gul
Name of E ator(it different from applicant) 1 Phone Cell
Street Adt-re3if' ' ilurl
ezt
4(6 `p1-`1 Ayiy\ 4o ( -g403.34
City/Town - MA ZIP
Name of Owperis)of Property Phone Cell
(fit►Cep ? c ' Ktan -- ,j. L Z
Street Address
SE ‘bayia C 1Yzci
City/Town MA I ZIP
jeatelf:CA-b ITO I_ CZ(t19-3
Other Contact 1 Permit Fee Received No( ) Yes( )
Description,loatlos 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(es; pipes/able lines etc..)Please use reverse side if additional space le needed.
RECEIVED
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SEP 212023
BUILDING DEPARTMENT
Insurance Certilkate 0: i J pc A g 1 `.�„(j 3(1 Z� -
Name and Contact Information ofInsurer: �
Q8)(2-'CS r� r1r 1,tYa(v. A-e .0 ( )1(a 19 i 1.
Policy Expiration Date: 5-
Did Safe N: 21
0 153 1
Name of Competent Person 1 as defined by 5211 C'MR 1.02):
-1 0 1. (i 1,ti' LL
1o12
Nbaachusetis Hoisting License I C✓ —
177
4 199I )L
License Grade: ()(/-D G 1 Y1efir _ Expiration Date:
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,
G.L. c. S2A, S21 CMR 7.00 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 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, AU'THORIZ S PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORE 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 LIMITED 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 DETAILS AND OTHER REMEDIAL MEASURES DEEMED
NECESSARY BY THE MUNICIPALITY.
THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDEMNIFY, AND BOLD HARMI FcS 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 7
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EXCAVATOR SIGNATURE(IF DIFFERENT)
edit Il,(� DALE
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OWNER'S SIG A'[UIt2'1I DIFFERENT)
DATE: 025
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