HomeMy WebLinkAboutBLDTR-23-001691 I 0.) lea CII Zg1Z2-
TOWN OF YARMOUTH
BUILDING DEPARTMENT Permit Number 13Lif)7e-Z_3
("(( • 1y 1146 Route 78,South Yarmouth, MA 02664 I _
E"\MATTA h 5.V_�' 508-398-2231 ext. 1261 Fax SI)8-398-0836 Date Issued C1 q I
Expiration Date C gig
$50.00
TRENCH PERMIT RECEIVED
Pursuant to G.L. c. 82A f 1 and 520 CMR 7.00 et seq.(as amended) .
fits PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION SEP 2 7 2022
Nairn elf Applicant 3 ixcava�+o tht.• Phone Cei BUILDING DEPARTMENT
By ------
Street Address Sd$• 411-o6S 3
3�� 2oJT+ Tao
City/Town MA ZIP
SandW.cl,. 02.S�3
Nana of Excavator of different fr ne sppRcantl Phone Cell
Street Address
City/fown MA ZIP
Nance of Owharts)of Property Af1�`e. Vo u t'n0►'e:6 r now Cell
Street Address
�- Holum Way
City/Town MA I ZIP
ya�rnovkl. _ I
Other Contact f Perttrit Fes Received No O Yes(
Description,location and purpose of proposed trench:
Please describe the exact location of the proposed trench and its purpose(Include•description of what is(or is intended)is
be laid/in proposed trench fee:pipes/cable Him etc-)Please use reverse xi*if additbd van
e Is needed.
fl5 \\c i .. of 110,E Sys+ tb-%
Insurance Certificate r: C 2 Yt a 8 }
Name end Contort information of Insurer:
SEAe,Ghw td1S•
Poiky Expiration Darr. 5- 1 Z
Diu Soho: Z02,2130VI53
Name of Competent Peron)as defined by 520(lit 7.02): --
1 of 2
Musaachuanta Hoisting License I HE- oqs11.0
•
License Grade: LA Expiration Date:
BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CER tirY
THAT THEY ARE FAMILIAR WITH,OR,BEFORE COMBIENCEMENT OF THE WORK, WILL BECOME FAMILIAR
WITH,ALL LAWS A ND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS.
G.L e. 92A, 529 CMR 7.00 et sec, AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS
REGLIATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR
SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH THE COMMONS SET FO'
BELOW.
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WORE ON THE PROPERTY OF THE OWNER, AND ALSO, FOR THE
DURATION OF CONSTRUCTION, AUTHORITJES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH TICE
CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS COVERING 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 MUTED TO EISFOIRCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF
THIS PERMIT,INSPECTION;MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES TAKEN BY THE
MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FARED TO
COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED
NECESSARY BY THE MUNICIPALITY.
THE UNDERSIGNED APrucANr. 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.
APPLI T SIGN RE 9 •it
DATE
EXCCVATOR/SIGNATURE(IF DIFFERENT)
/
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
_ _ DATE:
not( Tips rig—De me wile illetist
=nrViah"
Attiolitty
sitashim
coNpirkw0FAMII4AIL Dip
rue
--
2 of 2