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HomeMy WebLinkAboutBLDTR-23-001440 q-/G -z2_ boy•R TOWN OF VAR IG('T$i • f, DTP- -2 1 BUILDING DEPARTMENT Permit Number 0 0 I4WD i8( , ' -AI 1146 Route 18, South Yarmouth, MAC 02664 (,\rt.1TTI.<n z:L- :�s-3 s-7z 1 ext. 2�,1 Fax 5t:is-39s-use Date Issued � ,t--BOO 55/5/ Expiration I � 1; OyE TRENCH PERMIT [—SEP L132O22J Pursuant to G.L. c.82A §1 and 520 CMR 7.00 et seq.(as y - + aE.' MENT THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant R oba c•-r e, O.) Goa---) Phone Cell Street Address , 63 t v�-es \a. 1-1 City/Town MA ZIP . `)1Ki 0\-)S.Q.. NM et 0-fc,eafq _ Name of Excavator(if different from applicant) Phone Cell PIvvL Coff,C Street Address City/Town MA ZIP Name of Owner(s)q Property Phone Cell Street Address j G-t-t < Mill L10 City)Town MA I ZIP vl A e &A local 0 4..,'"? Other Contact 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. a5)I 1 I I IInsurance Certificate#: I C-2q I,Y, it-1).g— 10 Name and Contact Information of Insurer: F Rv tc r ci_J-3 3614-) Policy Expiration Date: b,,1)t-a.a.. Dig Safe ff: IName of Competent Person(as defined by 520 CMR 7.02): rA 1 X< ca cii t�C-,Q 1 of Massachusetts Hoisting License 41 Ft.. Z 1©&(03 License Grade: c?-`A Expiration Date: S ( 1 t,'a"1 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. S2A, 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 WILL 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 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 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 ENE 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 SIGNA RE /Ir; L -r�1 , , DATE)- EXCAVATOR SIGNATURRE(IF DIFFERENT) V DATE OWNER'S SIGNATURE(IF DIFFERENT) 1i�E ^ GYM✓ 1.1,;"-Ge-1,..--DATE:_____ _ Fur CII owe use--Da, PE'Ri►t1T A>�LU6�If,M� not writ*in this'steam • ;... S A PERMITTINGAUTTIORITY Fa tYD:tiiDITloxs OF ANAL 2 of