HomeMy WebLinkAboutBLDTR-23-002223 # A 1,1 a .) itA )oizs)7
TOWN OF l'ARNIOUTH
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BUILDING DEPARTMENT
1146 Route 28,South Yarmouth, A 02664
508.398-2231 ext. 1261 Fax 508-398.0836 Permit Number 131,J) Tye__Z 3—
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Date Issued 00 Z-Z1,3
Expiration Date CV-At-qt.) 61Cia_
$50. I
TRENCH PERMIT
Pursuant to G.L. c. 82A §I and 520 CMR 7.00 et seq.tias : 0 ended)
nits • .MIT N1UST BE FULLY COM' : D PRIOR TO CONSTOKRA TION
Name of Applicent b 3 6 itcaveztio" kw-- Pitons Cell
Street Address ., Sdg' 411-0.53
"Sl-uk (4(14.- xi")
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City/Town r-MA ZIP
Sc\r44,6-. Ao, 02,V.Z
Name of Excavator of different irons SpPlicanit , , , Ceti
Street Address
City/Town MA ZIP
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Name of throws)of Property 700,rt t‘osk Pamir ca
Street Address
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%A 50 ' 2.S3 . itilt,
0A41 't-c).• &it'
Cityfroent MA I ZIP
10.t cnotski,
thine Contact [Permit lee Riceived ISo_i ) Yes( )
Deneriptien,location and purpose of prepared trench
Please describe the exact Iscatien&the proposed trends aad its purpose(include a description al what is for is intended)to
be hid in proposed trench ten;pipeskaidir Noss etc..)Please use reverse side If additionai'pace is
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Insurance Certificate Ot 52112111
Nam sad Cowart!aorta:askew.4 Insurer
i SCACAtz- YIS.
Pointy F.vpirstineTtat 1 Z,,1
I D41 Ilte°I Ld-r-b3 CO(AILIS
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, Nairn of Competent PPM*1311 defined by SU t Allt 7,02):
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Livens*Grade: 7,
2,(ii( 2).4
ion Date
SY SIGNSIVG THIS FORM, ME AalLicAl9T,owNEIL AND EXCAVATOR All, ACKNOWLEDGE ; C
THAT THEY ASK
FAmn.Llika WITH,ORwrrEL ALL LAWS AND REGULA , SIR iCl 'OFTHE O WILL
CAs WO a • D,IN GC; t
C.L. G �A► STE M1t 7.* at ANY C ICItAtt OIRDINAN'ti v-IA S
REGVIATIOPM AND THEY COVENANTWORK DO UNDER 3,
SUCH WORK WILL COMPLY THE WTTR IN ALL ° "
BELOW. C`TS AND WETIEI THE CtDNI3I'IIOi S
THE UNDERSIGNED tT AUTHO
C TO F OR
-rimXXCAYATQ U T SUCH ® ON THE O D , Ftla
A 4 ' C[ nott, A
ED BY AWN/ ALITY TO
EN1 * UPON THE PROPERTY TO t AND CT WOE Co •AMITY 111E
CO1 ATA
AWS AND REGULA t:iRS COVE SUCH WO
nil UNDERSIGNED C ,OWNER AND EXCAVATOR AG + JOINTLY
REIMBURSE THE MUNICIPAL ITX COSTS .*t ; , ,: SEVERALLY I
'4UNIC1►AuTy IN o r
INCLUDING I T NO? /T AND c _ O CONDUCTED
' BY
THIS PERIM; .4 MADE TO ASSURE C
ItC `'. " OF sTArit LAW AND CONDITIONS
OF
MUNIPAI1TY TO .°a: ° s M T 'THE
COMPLYaPUBLIC WHERE CANT`0 l€ O CA'VA WAILED TO
NEC ARY BY THE M'IJNI A� ,OLICE DETAIL:9 AND on= DFEmED
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE IoINIT> ' AND SEVERALLY TO DEFEND,
INDEMNIFY,AND HOLD EARMLSES TER MUNICIPALITY AND ALL OF I'I'T AGENTS AND
EMPLOYEES FROM
ANY AND ALL LIABILITY,CAUSES ACT/ON,C ,. AND EXPENSES RESULTING FROM OR
ay ANY INJURY. DEATH, DAMAGETO ANYARISING O
CONDUCTED UNDER TNIF ICI. DI! PROPERTY ?U G 0
APPLI, • SIG RE
DATE 10
d
EXC VATOR.IGNATU (IP DIFFE T
11
OWNER'S SIGNAT'UREtIF DIE&' :RM'
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