HomeMy WebLinkAboutBLDTR-23-002220 b?a/fri6 L--
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TOWN OF YARN1()UTI-1,df.Yitit.
BUILDING DEPARTMENT Permit Number
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.8 feYii ,3 1146 Route 28,South Yarmouth, MA 02664
508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued O 0 ZZZO
Expiration Date oufgooct t
• 50.00
TRENCH PERMIT
Pursuant to G.L. e. 82A 41 and 520 CMR 7. et seq.(as : ended)
ruts PERMIT MUST BE FULLY COMPUTED P' SW TO CONSIDF,RA nos4
Name of Applicant b s 6 cki,A to,L. Phone Cell
Street Address SOS- 411 obS.3
• -1k,\ R ,, rao
CIty/Town MA ZIP
A_ 02,5(01
Name of Etaavator if din'etlest Tram ispplicea -ti Photos Cell
Berme Addribes
City/Town MA ZIP
_. .
Nam.of Osviserts)of Property 1/47001, (Aar t ?bone ea
Street Address
I 3(06 Soh Sea Arc
Cityfrown MA I ZIP
104 Moukk, .
other Contact _ "permit Fee Received No( ) Yes( )
Deseriptiois.location an pupate of proposed trench:
Please describe the matt location of the proposed treat*mad its purpose(Include•description of what la(or is int . ,)to
be laid in ropesod trench(eg;pipaileahle lines ele-) ' use reverse side if additional space Is needed.
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Insurance Certificate Pr 52518i1-1 --
Name and Cowart Information of lostirer:
Seitec,61- tAS.
Polley Espiratina flair 5.I II 2,4
Dig Seib II: 1
LOZ-06091 3S-
Nam.of Competent Penne its defined by 320 t`Slit 7.02):
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1 of 2
Itetsssoctiumfts Hoisting License HE- otttrIo
i(11 2,4
G 7,A
BY SIGNENG THIS FORM.THE APPLICA , OWNER.AND EXCAVATOR ALL AC WAR AND CERTIFY
MAT ARE FAMILIAR WTTWa,OR,BEFORE COMMENCEMENT OF THE WORE.WILL BE ME FAMILIAR
ALL WS AND REGULATIONN APPLICABLETO WO • •. `D.INCLUDING G
• t 520 CMR 7. APPLICABLE C MUNICIPAL O�' S V- `V4'
• GL THEY A AG T t.WO NE Ul TII R R PERMIT ISSUED FOR
.. O WILL COMM THERE , . .;crs AND wrp I' TIIE copnarnoNs A
rHE .i a IC. OWNER A O: A TO i FOR TRE S AM)
EXCAVATOR TO V, TAKE SUCH WORK ON ME PIO OF THE OWNER. AND ALSO. FOR THZ
DI,- TION OF cortsTatienotq, PERSONS MILT ` t r ' , a, Y THE MuNICIPALTIT TO
ENITII UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK l'OR CONFORMITY WITH THE
Cor4Drnoms ATTACK HERETO AND THE LAWS (ULA COVERING SUCH WORK.
TIM UNDERSIGNED APPLICANT.OWNER AND EXCAVATOR AGEEK JOINTLY AND IlER L.t Y TO
C"= :f THE MUNICIPALITYNY FOR A AND ALL C AND SII INCURREDBY •,
MUNICIPALITYIN CONNECTION WITH PERMIT AND WORK CO I 31 t
LNC'LLIDING SLIT NOT LIIW]CI`I ►'TO ENFORCING r • . OF STA. W AND CONDETIONS OF
MTT. CTIOESI MADE TO C• insissvara.AND MEASURESTANEN BY THE
mtrfflapAisryO PUBLIC WHERE THE APPLICANT OWNIER OR EXCAVATOR aAs FAILED TO
• 1 I t 1 w . • y,';INCLUDING POLICE META 5 AND OMER REMEDIAL MEASURES DEEMED
• A. Y BY THE MUNICIPALITY.
tRIL UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AM)SEVERALLY TO DEFEND,
ENDEMNIFY, AND HOLD HARIWISSE THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM
k LiAsu I'TY,CAUSES OR ACTION.COM, ANDj►r ;• ES A t OR ARESDIG OUT
DP ANT INJURY. DEATH, LOW.. OR DAMAGE ANY PE* �.= .,; OR PRO wogs
ON DUCIEDUNDER Tuts I' tki
• LI T SIGN IRE
-14 DATE l 0• ?Ai-2Z
LECAVATORRIGNATUREDOTE T)
DATE
OWNER'S SIGNA ru REi IF DIFFEREINI)
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