The URL can be used to link to this page

Home My WebLink AboutBLDTR-23-001957 rr) (Li le d- iD//3/Zz- TOWN OF \ ARNIOt'TN o BUILDING DEPARTMENT Permit Number 6 L b -23 (<>1.**"4 c` 1146 Route 28, South Yarmouth. MA 02664 �sU'x' :,08-398-2231 ext. 261 Fax 508-398-0836 Date Issued 0 a )9 5 - R `� Expiration Date (.,;I a2gW-- SO 66 OCT 07 2022 �-— TRENCH PERMIT BUILDING DEPARTMENTBY rsuant 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 Applicant Eli is / c ,sy- Phone Cell -13 Street Address 3 an pY'.r,tp ,a SO�' 3 �`` City/Town MA I ZIP 10.)67S Nate of Excav r(if different from applicant) Phone Cell Street Address City/Town MA ZIP Name of Owner(s)of Property Phone Cell Street Address 5(, I t9 botq --� City/Town MA i ZIP Other Contact I_Permit Fee Received No( ) Yes( ) Description,location 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(eg;pipes/cable lines etc.,)Please use reverse side if additional space is needed. Insurance Certificate#: L� Name and Contact Information of Insurer: ScS c 14a I Policy Expiration Date: (d 13lr Dig Safe#: 0' � a , og R l�I -2� J Name of Competent Person(as defined by 520 CMR 7.02): oL7 Ind G! 1of2 Massachusetts Roist tg License# (+ `o License G I I — - - (Cei,vet I 1; 6e:) �' BY SIGNING THIS FORM,THE APPLICANT,OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY TEAT THEY ARE FAMILIAR WITH,OR,BEFORE COCOMMENCEMENT OF THE WORK,WILL BECOME FAMILIAR WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED, ORDINANCES,DICLUDIN1GOSHA E. A' TIONa G.L. c. MA, 520 CMR 7.A0 et seq., AND ANY APPLICABLE MUNICIPAL ISSUED FORD REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORE DONE UNDER THE PERMIT SUCH WORK WILL COMPLY THEREWITE IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH BELOW. THE UNDERSIGNED OWNER AUTHORIZE 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 ROD CONFORMITY 'WITH THE AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALTTY TO ENTER UPON THCONSTRUCTION, PROPERTY TOMONTTUR AND INN THE WORK R CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS GOVERING 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 Tuts p MIlAND TUE WORK CONDUCTED THEREUNDER, OF STATE LAW AND CONDITIONS OF INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS TASEN BY TIC THIS €,INSPECTIONS MADE TO ASSURE COECT THE PUBLIC WHERE MPLIANCE TUEREW1TH,AND►MEASURES HAS MUNIC1PALITY TOHEREW CLUDINGPOLIICEDE A�ANDOi ERRED OR APPLICANT OWNER EXCAVATOR FAILED COMPLY 7[7�� IAL MEASURES DEEMED NECESSARY BY THE MUNICIPALITY. TO DEFEND, THE YSIGNED APPLICANT, NER AND THE MUNICIPAVATOR AGREE JOINTLY ALITY AND ALL OF ITS AGENTS AND�Y�FROM ANYINDEMNIFY,AAAND HOW RESULTING FROM OR ARISING OUT ANY AND ALL LIABILITY,CAUSES OR ACTION,OR DAMAGE TO -AND�R PROPERTY DURING 'THE WORK OF ANY INJURY, DEATH, LOB CONDUCTED UNDER'I PERMYT. APPLICANT SIG 1. , t ' - 1 Ci.' ", ` DATE -- 31 — EXCAVATOR SIGNATURE(IF EFFERENT) DATE 0,4Er SIGN U-7YERENT) . 1 --L DATE: e c=? _. . .. . .. .. . . - For tbliet'sore_Ds flat write Tod s . , - • . passurAtoms -= . . • -= - - _ °1 °" : `ss I Commonwealth of Massachusetts lilt Division of Professional Licensure Pisislinifiltijtneer HE-028673 a Olpires:12/30/2022 LAURENCE I5ELUS Atk , 8 NORTH ST.Ifi 02631 DENNIS PORP)NA i()/SVILII5* Commissioner btnafic., 4 Hoisting Engineer Restricted to: HE-24-Excavators inOcalosesAForEa Ca)/Center:(888)344-7233 Contact OPS/:(617)727°,3c1:00entocar vilis:it/508)8204444 .inass.gov/dp1/opsi TE AW�' CERTIFICATE OF LIABILITY INSURANCE DA12/13/2o2n1 YI THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT RogersGray, Inc.-Kingston Branch PHONE FAX 63 Smith Lane INC.No.Ext):508-746-3311 {Arc.No):877-816-2156 AIL Kingston MA 02364 ADDRESS: mail@rogersgray.com INSURERS)AFFORDING COVERAGE NAIC# INSURER A:West American Insurance Company 44393 INSURED REID&LA-01 INSURER B:Arbeila Protection Insurance Company,Inc. 41360 Reid&Laurence Ellis dba Ellis Brothers Construction 23 Enterprise Rd, P.O.Box 59 INSURER c:Associated Employers Insurance Company 11104 Yarmouthport MA 02675 INSURER 0: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER:2114965942 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRL TYPE OF INSURANCE INSD[SWVD POLICY NUMBER (MM/ODIYYYY) (MMIDDIYYYY) LIMITS A X I COMMERCIAL GENERAL LIABILITY BKW58371201 3/1/2021 3/112022 EACH OCCURRENCE $1,000,000 I CLAIMS-MADE X OCCUR 1 DAMAGE S l RENTED PREMISES{Ea occurrence) $100,000 MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY JECT IO- 1 I LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ B 1 AUTOMOBILE LIABILITY 1020002607 6/9/2021 1 6/9/2022 (Ea aaiNdEL SINGLE LIMIT $ i ANY AUTO 1 BODILY INJURY(Per person) $250,000 OWNED I SCHEDULED i BODILY INJURY(Per accident) $500,000 AUTOS ONLY AUTOS 1 X HIRED X NON-OWNED PROPERTY DAMAGE $100,000 AUTOS ONLY _ AUTOS ONLY ' (Per accident) $ UMBRELLA UAB OCCUR I EACH OCCURRENCE $ EXCESS LIAB i 1 CLAIMS-MADE] I AGGREGATE $` 1 I DED I I RETENTIONS I $ C WORKERS COMPENSATION WCC-500-5000706-2021A 12/3/2021 12/3/2022 STA UTE ER- AND EMPLOYERS'UABILITY Y/N ANYPROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $100,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $100,000 If yes,describe under 1 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 I I I i DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more spacers required) Certificate holder is listed as additional insured under General Liability for on-going operations when required by written contract or agreement. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth 1146 Route 28 AU REPRESENTATIVE South Yarmouth MA 02664 —D-' 7.„-a _ CO 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD