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HomeMy WebLinkAboutBLDTR-23-001443 /rlii-1lty TOWN OF YARMOtT11.I q-/q-ZZ • ©f Y"qR BUILDING I)EPARTMENri' Permit Number &p e -02 _- n� • y 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued t d iq ,F3 _ Expiration Date C r1 kl I 111 ECEIVED TRENCH PERMIT _ Pursuant to G.L. c. 82A 01 and 520 CNIR 7.00 et seq.(as amen, BUILDING DEPART NtmeutA Iksn! �7. �,�. yy Cell MENT Street Addrett City/Town MA ZIP Nairn a Excavator(if different front appllctnt) Korai Cell Street Address City/Cowes MA ZIP Naga of Ow rani s►of Property PI or a Cell Street Address Ctty/I'own MA 1 LIP C) -'C7 t>therr Contact I Permit tree Received Nu( ) Yes( ) Description,iocadorr and of proposed treochs Pirate describe the exact Location of the proposed trench and its purse(include a description of what is(or is intended)to be laid in proposed tr+esxh(cg:pipes/cable lions eic.)Mime r use rererw side If additional space is needed. & a C)1' ,.i'Oi'"-e's Insurance Certifkate t►s ante and Contact Information or Ir uner i7) t �-'r Y � 'i�,i rat ' _. i' ..- C` ` Polk/Etpiratkut Date: ')lai ot-9 Did Safe f: C - D/f 5141 Nun*of Competent Perrot I kfined by 520 C'llit 7.t}11: ' t 1 o12 Haswidnifottta Hoisting Licento• (: i Lkense Grigiet , Expiration Date: / 2 3 BY SIGNING THIS FORM, THE APPLICA,NIT, OWNER, AND EXCAVATOR, ALL ACKNOWLEDGE AND CERTIFY THAT THEY ARE FAMILIAR WITH,OR, BEFORE CO CEMENT OF THE WORK,, WIlL BECOME FAMILIAR wiTH,ALL LAWS AND itEGULA rioNs APPLICABLE TO WORK PROPOSED.INCLUDING OSHA REGULATIONS, G.L. c. I2A, 52* CM@ 7.O et t.tet., 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 RESPECT'S 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 . : OWNER. AND ALSO, FOR THE DURATION OF CONSTRUCTION, AUTHORIZES' PERSONS DULY APPOINTED BY THE MUNICIPALITY TO ENTER UPON TILE PROPERTY TO moNriou AND iNsTier THE WORK FOR CONFO ' WITH 'THE CONDITIONS ATTACHED 11E11E1'0 AND TEE LAWS AND REGULATIONS COVE' G SUCH WORK. THE UND IGNED APPLICANT,OWNER AND EXCAVATOR AG' ' JOINTLY AND SEVERALLY TO ' URSE THE MUNICIPALITY FOIE ANY AND ALL COSTS AND EXPENSES IN • • *.a. BY nos MUNICIPALITY IN CONNECTION WITH THIS P'ERMICT ANTI THE WORK CONDU a THEREUNDER, INCLUDING RUT NOT LIMITED TO ElklEORCING TIIE 1 OF STATE LAW AND CONDITIONS OF THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND ' ' ' 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 NIUNICIYALITY AND ALL. OF ITS AGENTS AND EMPLOYEES FROM ANY AND ALL LIABILITY, CAUSES OR ACTION, COSTS, AND EXPENSES * •ULTING FROM OR ARISING OUT Or ANY INJURY. DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT. APPLICANT SIGNATURE -7; - - OATH - EXCAVATOR SIGNATURE (IF DIFFERENT) IEVIE — — OWNERS SIGNATURE(IF DIFFERENT) DA It': (11 14, 114 ED 111 A Owe • ofApvMu ° 2 ot'2