HomeMy WebLinkAboutBLDTR-23-00168 OF•Y.yR `
[OWN OF YARMOUTH
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{• 4 BUILDING DEPARTMENT Permit Number
p(- At )51 1146 Route 28,South Yarmouth, MA 02664
IC' .. r j„ y 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued j .".
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Expiration Date 1' ()O `� j
$50.00
TRENCH PERMIT RECEIVED
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as am tad
THIS PERMIT MUST RE FULLY COMPLETED PRIOR I O CONSIDF.RA f EP 2 7 2011
Name of 1,ppiicant � NC oCi�
RdexERT 6rv� Phone Cep [ ;` PA rn" T
Street Address `► "`
3t,,,3 (6'4 PA r -( -`�� 1- /
City/Town MA ZIP 77 2-t -3 14
5-0V'�tt urt( to I O
Name of Excavator(if different from applicant) Phone
Cell
Street Address SANS
Citylrown MA I ZIP
Name of Owners')of Property `` Phone
( OTtf' SL.W 'to P i Cell
Street Address
100i cO1) ;Ab
Chylfown MA I ZIP
E0 Vekkiiioctrii 11.1/44 I 0 w
Other Contact �'`�
I Permit Fee Received No( ) Yes( )
Description,locadoa 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 tea;pipes/cable lines etc..)Please use reverse ride if additional space is needed.
S it - s iAL o
Insurance Certificate Or dpik
Name and Contact Information of Insurer:
1+Li e 1-0 or r JAT WJF\C tIJ G e64-71-Catue,
Policy Etpiration Date:
Dig Safe
,Name of Competent Person Ias defined by S2t1('MR 7 62):
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Liceme Grrt4v C----- A_______ _ A
8 V SIGNING TRIS FORK TUE APPILIC.'ANT, OWNER, AND PACAVATua ALL ACRNOWLEDGE ANT CZRTIFY
TEAT THEY ARE,FAMIIJAR wrcii,on,ok..;:ro t F. COMMENCEMENT Or TIIE WORE, WILL ;REC"..:%.tlitilE,FAMILIAR
wrm,A f-t, LAWS AND RFC:UP:A:TIMM APTe'7.,KC,A F/F..,E ro VtIOR.K PROPIKED:aNCLUPENG OSHA 't2GITTLATION>,3,.
GL c., 9 . 52f0 CRIIR 7,CK) Tit s;,,N.- ANAI:,-0 ANY AMILICABLE M1.1-N-K:17Lq., OragTAANCT.?.-S, 31'..I..AI7;.7 MVP
REGULATIONS AND THEY COVKNA Ntr AND AGREE THAT ALL,WORN DONE tUNDER Ti!E PERMIT ES,S7CJ ED FOR
SUM, WORK WELL CON4 rIC THEREWMF IN ALL RESPECT AND '70,77-i TIT coNignIONS 8g FOralg
RIF-1.051,
THY, ':;11-7).F.FMg-GNFIF,q ,7MINER AUTU,ORRIT. 'rHE i'IPPUCANT TO AFTPF4V FIal TUE FERMAT AND Tiit:
r.INCAt,VA 79K :P.r.„Z QIN:DER-7A kif :PliCifkl VI'017,TL ON THE PROPERTY OF TUX OWNER„ AND ALSO, FOR THE
9URA TEON OF
CENTNTI,:Em UIlTtUAF lPiREOMM11 FTillHONrRiTIrZk OMA' O RF, VAJNFE paT.FrRr yT Ha) 7 /ON2CUWMROPNOMOOV ( lO E
AND Ilirk,'LAWS AND UGC/ATMS C-OrEMNG SUCH WORA
THE k_iNDIFR.SRGNEIP 4PPLICANT,()INNEN,AND EXCAVATOR AGREE jouvirLy AND SEVER_ALLT TO
REIMIIIIMSE IRE MUN7CIPAILtrIne FOR ANT AND ALL COSTS AND EKFT,NSFS INCURRED it If TYRA'
4 LI NICTAUTY ZN C.:ONNE0,10N%um 771.IS TIERMET AND T . 'WORN CONDUCTED TWOREUNDE.R,
$11.1.7LUOING R UT NOT LAIKETED TO EtY500.0Nfal TE117,REctt/R- MEWS 07 STATE LAW AND CONDEITIONS OF
THIS PERMIT,iNSTECTRON3 A4A3E TO 4t5EIVIIIE COMPLIANCE TtirEALSWIllii,AND MEASUM TAXEN ro I VIZ
muNicipArsre TO PROTECT THE FUELEC IIVRERE'ME APPLICANT OWNER 0R 147,XCAYATOR HAS:!I',iIkULED TO
COMPLY 1111EREWITD ANCLUDING POLICE)0:771"AILS AND OTHER PJEDIEARA.g.;MEASUram nEvouso
NECFSSARY BY THE MEINVI-IP4 LT-1M
T7W. UNDERSAo;Ni;•y.,,Ty fur Fc-',AN'ir, oilmri'M AMU 'EXCAVA,:MR AGICITI°1:4i:SCANTLY AND Sii7, ','I'. .7IrZial,41:' TO 1FNK),
PifIWATNPFT, ,8,;',73; r,IMT, MI)17,:it,'LLE,Fp5 Ill IK:EVA,17,Fry AND AL op' ni7 AGgytyirg AND Emi,T,Lcryrszs mom
ANgp A1.4, 7i),uv_..inlr, icAu,s3i5 og.,, Immilzov, co5To AND EXPENSV3 RESUILTINf; FiV)14 OR MUSING OUT
or ANY Teti37iMI', 1)V.,.ATIK, ii,..aaz:c.5,. OR DAMAGE TO ANY PETt'CION OR PROM:ITT DI.PAW47,4 III,M WOISCK
CON DUCTED Zir-PtIMC,,'111.9 PERNLY11%
' / (-,II-77:/. / c71
--. DATE __C " _ )
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EX:CA V A TO R,SIG IN A TVRIE(0.7 TOTE REN T)
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OWNER'S SICNATIJ RE(W DIFFERENT)Fi4,7 tii-117i'v;;umr- -..E4 nekl IT rftli AO vz::',PI,g, -
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