HomeMy WebLinkAboutBLDTR-23-002216 TOWN OF YARMOUTH m i)e 1 -
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qR o BUILDING DEPARTMENT Permit Number W) W -023-
f` g `C 1146 Route 28,South Yarmouth, NIA 02664
N ,," „ „ ..; 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued 02-JC,
Expiration Date e 121P
$50.00
TRENCH PERMIT" a
ED
Pursuant to G.L.c. 82A §1 and 520 CMR 7.00 et seq.(as anitetidFed-� .:
1 HIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION OCT 25 2022
Name of Applicant
� �� _�_ Phone Cell [ _._ _
U\�v�. C-XCG.JG\-t \ BUILDING DLPARIMENT
Street Address l�� 3C\ OU CA
By
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City/Town MA ZIP
Name of Excavator tit different from applicant) Phone Cell
Street Address
CityfTown MA ZIP
Name of Ownerts)of Property -Phone Cer
Street Address —,tC--4C0C 504 - 5G-1—S085
Z.C\ C < Cu\\ \kOC
Citylrown MA t ZIP
``C"'‹cNNOl.)-\h { ci T
Other Contact I Permit Few Received No( ) Yes(
Description,location and purpose of proposed trench:
Please describe the exact location of the proposed trench and its purpose(Include a description of what is(or Is intended)to
be hid In proposed trench(ea:pipes/eahk lines etc..)Please use reverse tide N additional space is needed.
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Insurance Certiikate tr: t-k t+
!lame and Contact Information of Insurer:
INNAet tcr„,.r. loe\ C �� %w\"n .1�� ,\ 5C)�S 1�o L6
Pulley Expiration Date: 5�e
Dig Sat,if:
1-
0
,Z1-
LA30\
j Name of Competent Perna Jos defined by 520('MR 7A2):
`m lee 3 e\ch
loft
Maaelehialatig llioirtbx�"Cent a I RC t "�
Lkense Gradra 4FgEspy DOW I t,� - 1
BY SING THIS FORM, THE APPLICANT,OWNER, AND UCAYATOt ALL ACIENOWLEDGE ANT)(littr#Y
'WHAT THEY ARE FAMILIAR wr'CH,OR,$EFORE COMMENCEMENT OF THE WORK,WEIL BECOME FAMILIAR
W1TB.AIL LAWS AND REGULATIONS APPLICABLE TO WORK ntOrosErt,LNCLLTIVEG OSHA REGL'I.ATW NB,
t+ l2A. 520 CMR ?.M et seq., AND ANY APPL/CA I g MUNICIPAL ORDINANCES. IIY4AWS AND
REGULATIONS AND THEY COVENANT AND AGM THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR
BIlCH WORK WILL COMPLY THEREWITH LK ALL RESPECTS AAHD WITH THE CONDITION'S SET FORTH
BELOW.
THE UNDERSIGNED OWNER AUTHORIZES TILE APPLICANT TO APPLY FOR THE PERMIT AND I HE
EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER. AND ALSO, FOR THE
DURATION OF CONSTRUCTION,, AUTIioRI7.F.5 PERSCyNS DULL' APPO !' 'IEI3 SY THE INUNICIPAt.ITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR C+ONFOR1MITiY WITH THE
CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS GOVERING SUCH WORK.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE XHNTLY AND SEVERALLY TO
REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE
MUNICIPALITY IN CONNECTION WITH THIS P4[MTf AND THE WORK CONDUCTED THEUVNIWR,
INCLUDING BUT NOT uMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF
TIM PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE TfTEREWITg,AND MEASURES TAKEN BY THE
MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILKO TO
COMPLY THEREWITH LNCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DF.EUMZD
NECESSARY BY THE MUNICIPALITY.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDEMNIFY,AND HOLD HARMLESS THE MUNICIPALITY AND ALL OP'ITS AGENTS AND EMPLOYEES
ANY AND AIL LUABIIX Y,CAUSES OR ACTION.COSTS,AND EXPENSES RBSULTTNG FROM OR ARSIN FROM
E OUT
OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THY WORK
CONDUCTED UNDER THIS PERMLET.
APPLICANT SIGNATURE
DATE C 1.1=
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
'S SIGNA IF DIFFERENT)
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DATE `� c�
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