HomeMy WebLinkAboutBLDTR-23-002095 m 1..e0( 10 lic(
0;o- 'f()%NiN OF YARNIOUTH
ov.YAlit
',a BUILDING DEPARTMENT Permit Number 3 1./DTE-23
40.'1 ).,.9 114i Route 28,South Yarmouth, MA 02664
508-398-2231 ext. 1261 Fax 508-398-t/836 Date Issued D.D2--0q5
Expiration Date C.-0 ci OCP-4-7
T NCH PERMIT
Pursuant to G.L. c. 82A and 520 CAR 7.00 et seq.( ; ended)
rats PERMIT MUST BE FULLY COMP ' D PRIOR TO CONSIDERA TION
Noss a Appacsitt s 6 ti,,,,c4,404.4, cott
Street AMerm 5O g till-pi,S"3
1 \S 1464,1,\4, ‘150
City/Town MA I ZIP
So%rukt0, Pko, 02:cc
Naos of Excaildetit titMenet fro*rapp grant)
Serves Address
City/Town idtA ZIP
Name of°worsts)ot Property ki eko
t Plass ces
,
Street Address
7,Es Iv.t41-1csCnt•- tZ•00-a
CkyiTswitt MA 1 ZIP
tio,(00A,
()doer Contact 1PeCe4d Pis( ) Yes )
Deseristiess,locadoa and • ••• of proposed tresehs
Please describe the nut Issetion of the proposed trench sad its plumose lineludita descripdtes of what is for is intended)to
be bag fn•proppsed use&(es;plgsattabkt lines eft-)Please teat mastld If additional spare I •
11151-0A0A-ioy• Ok t;(- caltS4kj
OCT 18 2022
BtJILDINU r'e-‘I‘I 1VtL.N1
a' a — BY
Insurance Certillesitt ift
Neal*sad f'ontset information of losoner.
SZAfiCku,
Folk/Etplestion near: 51 ti LI "
Di*Sste 1,011- b °10
Nese of Costae time Per*oa I ate dined hi sza(ma 7.4,2):
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1 of 2
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ration Date:
Y SIGNING `IIRS FORM, THE APPLICANT,OWNER, EXCAVATOR ALL ALIENOSIILEDGIE AND CE
MIT
THAI' 'I ARE FAM OR,BEFORE CO CEMENT OF THZ WORK, YiFCOME FAMILIAR ALL LAWS MOD REGUTAT/ONSC WORK ....• "D.INCLUDING OSNA IREGULATK)
C#, • 520 CMS LN, A. . Al. ORDINANCES, IFYt-LA; S AND
SUCH REGLLA
NS) AND Y Cu' AG T WO UNDERt.. * . O/FOR
COMPLY Tfizitawnlit D ALL 1.4' :CTS AND WITH rite CONDmok4E SET FORTH
c _••W
THE UNDERSIGNED OWNER AUTHORIZESTit APPLICANT Y FOR
EXCAVATOR TO UNDERT SUCH IVOR& ONTB,S PEOPERTY OF OWNER. AND ALSO, FOR nag
DURAIIII N OW CONSTRUCITON, A f PA...' Y e t
ENTERUPON THE PROPERTY TO IMCONfrOR .E "I' iCUNICIP 1'E
CONDITIONS ATTACHED a' ' •r D THE LAWSRE COVE SUCH FOR
I<RMI'i"Y+ H
WO
THE UNDIIRSIGNIED APPLICANT,OWNERAND raeAV ATOM AGTUIM JOINTLY LLy TO REIMBURSE TIlE MUNICIPALITY IVOR ANY AND ALL COSTS AND 1011100113 THE
MUNICIPALTTY IN CONNECTIONrrAND 1111 WORK CON ,+BX^
INCLUDING BUT NOT LIMITED O tort:Mem I Of STATE
c
LAW AND CONDTITONS OF
TO C T LIC W RE E Ak''LICANT O I'Mgiv'MPH ALITY OR B:ECAVATOR HAS FAILED TO
COM r 'Y THEREWITH INCLUDING LUDING POLICE > LA ., r
EY BY TILE MUNICIPA
ritz UNDERSIGNED APPLICANT,OWNER AND 1RXCAVAMOR AGREEJOINTLY AND
•I HOLD HARM TILE;'MUNICIPA AND ALL OF ITN A LLY TiJI.
A LIABILITY,CAUSESOR A - TS, A s a I3 +AYEI
OE A INJURY. DEATH, DAMAGE A NI OR I„OUT
: N C UNDER THIS pawn* O DU R
APPLI `I%SIGN RE
DATE 0 n' it
EXjC' VA TOR IGNATURE `Dim 11
DATE
OWNER'S IL,NA'r! (W O
DATEt
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