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TOWN OF YARNIOUTH
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_. iv•T, "1"0 BUILDING DEPARTMENT Permit Number 81_,I)TP
1146 Route 28, South Yormouth, IA 02664
06 ) 111-11/
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- m 508-398-2131 e Fax xt. 1261 508-398-0836 Date Issued
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Expiration Date a-.4f9 g)14
$50.00
TRENCH PER1I1T
Pursuant to G.L. c. 82A §1 and 520 CNIR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Nance of Applicant R, (.... c--,N),c\--:-;r-,\ Phone Cell
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Street Addrees
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City/Town MA ZIP
Name of Excavator(if different from applicant) Phone Cell
Street Address
Cityffown MA ZIP _
Marne of Ow neri s)of PimPertY .. --ar,)-e9c/.5--' Phone Cell
Street Address 6 /7—76-3- 0,--a.3
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Other Contact I Permit Fee Received No( ) Yes( )
Description,facade/a and purpose of proposed trench:
Pleare describe the exact location uf the proposed trench sod its purpeor(include a description of what is(or is intended)to
be laid in prripowd trench(rg;pipes/cable lines etc..)Please use re verxr side if'With:nod(pace is needed.
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Insurance Ceriincale Ss 4-,rn
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Natty and Contact Information of Insurer c A- `:, v-„,,,,.--,-„{-4:
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Polk1 Flpitstkm nate: II'Ai a9
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NIUTW of Competent Person ilk/tkfined by 329(MR 7 U2):
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Maa,achusetta Hots' tin LE:ense \4: 0 )
License Grade: 1 , LA* Expiration Date: ,f.)* 3
BY SIGNING THIS FORM, TILE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH,OR, BEFORE CO I CEMENT OF THE WORK, WILL BECOME FAMILIAR
WITH.ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED.INCLUDING OSHA REGULATIONS,
G.L. e. 2A, 5211 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 * ISSUED FOR
SUCH WORK WILL CONIPLY THEREWITH IN ALL RESPECTS AND wrrn THE CONDITIONS SET FORTH
BELOW.
THE UNDERSIGNED OWNER AUTHORIZES TILE CANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF OWNER. AND ALSO, FOR THE
DURATION OF CONSTRUCTION, AUTHO PERSONS DULY APPOINTED BY : 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 WORE.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AG ' JOINTLY AND SEV' ' LLY TO
REIMBURSE TILE MUNICIPALITY FOIE ANY AND ALL COSTS AND : I EN '' IN ' By 21:
MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUL TIMREUNDER,
INCLUDING BUT NOT L t TO ENFORCING THE REQ(J • ' OF STATE LAW AND CONDITIONS OF
THIS PERMIT,INSPECTIONS MADE TO ASSURE CO CE THEREWITH,AND ** ' '• TAKEN BY THE
MUNICIPALITY TO PROTECT THE PUBLIC WITERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO
COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEI/IAL MEASURES DEEMED
NECESSARY BY THE MUNICIPALITY.
THE UNDERSIGNED APPLICANT, OWNER AM) EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDEMNIFY, AND HOLD HARMI ESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM
ANY AND ALL LIABILITY, CAUSES OR ACTION, COSTS, AND C " SES ' ' 'ULTING FROM OR ARISING OUT
or ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PE' N OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNA '
DATE
EXCAVATOR SIGNATURE (IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DA'TE:
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