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HomeMy WebLinkAboutBLDTR-23-002161 iO I u(f12 of•YqR- TOWN OF YARMOUTH • . o, BUILDING DEPARTMENT Permit Number '5L-h O _ 1146 Route 28,South Yarmouth, NIA 02664 MATTACM «�/_ 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued / ' / Expiration Date £ IL - ) PPvED TRENCH PERMIT Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended) OCT 19 2022 THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Ell!, )1 NG DEPARTMENT Name of Applicant Phone Cell .0- 'RObeC�I TO$-131- al/55 Street s + cA cc Email Address: `tie \' . ' ( �kt LOAM City/Town MA ZIP Name of Excavator(if different from applicant) Phone Cell Street Address Email Address: City/Town MA ZIP Name of Ownertsl of Property Phone Cell dre c k- KV SSv� a70 Street Address c C©, \,n C�/1CL5� �C\ Email Address: City/Town MA MA ZIP Other Contact Permit Fee Received No( 1 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 leg; pipes/cable lines etc..)Please use reverse side if additional space is needed. tG. vt c e c G Insurance Certificate M: 1 `` ) 45`�/ -7e �V N ,,J lG" Name and Contact Information of Insurer: 'Q lo5 rkSok and-- Policy Expiration Date: t C3 3-5 Dig Sate K: `a0a i Name of Competent Person as defined by 520.(MR 712): � � 2'oc Name of Competent Person(as defined by 520 CMR 7.02): 3 \Z6\06 -- Massachusetts Hoisting License# tcj?:17 License Grade: ra Expiration Date: 48 13 BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF THE WORK, WILL BECOME FAMILIAR WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS, G.L. c. 82A, 520 CMR 7.00 et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR SUCH WORK WII,L COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH BELOW. THE UNDERSIGNED OWNER AUTHORIZES 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 CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE 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 THIS PERMIT AND THE WORK CONDUCTED THEREUNDER, INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES TAKEN BY THE MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED NECESSARY BY THE MUNICIPALITY. THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND, INDEMNIFY, AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM ANY AND ALL LIABILITY, CAUSES OR ACTION, COSTS, AND EXPENSES RESULTING FROM OR ARISING OUT OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT. APPLICANT SIGNATURE �...... DATE (q t 4 EXCAVAT SIGNAT (IF DIFFERENT) ` DATE OWNER'S SIGNATURE (IF DIFFERENT) DATE: (0(t q[-k D - efts -Here PEIiIAI'PrtIIC seet�o� R� ICY" R 1 L\G A HIIII �` Aglr}rcativn Fee