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HomeMy WebLinkAboutBLDTR-23-001144 u TOWN OF A MOB J �H "�.�` `\ � B JIL 1 11 G DEPARTMENT e rnit N1.�1fl �IL�'E !`:-- . G. -. +23.— oI rb-- ( 1146 Route 28,South V.a n h ..r% �S 9!a ���jjj ,( , !� p Date }� ' Nt1;6p1�i'f%..r ntitR/_� .� .",. a� 'lY A Fax I( '..7 0 5.'l tf�' �;,�,✓lif,40.y .�iln J'r...� .. .....: � i y;, 4)S``=w.. to J 4,0 �/ TExpiratiOn .q `' r , ..er 9 5.7 7.. 0 gel 0 .,�v. :, TRENCH PERMIT RECEIVE ® Pursuant to G.L.c. 82A §1 and 520 CMR 7.00 et seq.(• amend )----------- THYS PERMIT MUS1'BE FULLY COMPLETED PAR TO CONSITlE ATI AUG 1 1 2022 �N' 4APPBicani-Bn\iJ _a / 8 1 p rc o• � Ce81 BUILDiNC� utNHKi ' ENT Street A J 5Or 3 o r� a. f v, �'� , l t, 91tr/Tosient Li MA ZIP Name a Excavator(if different from applicant) Mom�� m�, _...___Cedd..._,._ar�.,_,_ Strut Address City/Town MA ZIP - d Naves of Ownerial of Property Pb ,on Ced Street Address EV cV SC U r"C. isk..] LU Ctty/Towra MA I ZIP - Other Contact Permit Fee Received No( ) Yes( ) Description,location and purpose of proposed trincht - Please describe the exact locatives date proposed trench sod its purpc a(include a description of what is(or is intended)to be said in proposed trench(es;pipes/cable idea etc..)Please use reverse side if*OWE and space is needed. i1,1.o.t•c 61) v& c,1 ec. -ccaA • , � 1,jns l if di,i \re-A /1(11 � 9 via �a ) k: 2C L r 9- Vi se Lirtym _2,‘Rzw1A:c, 'PM\-)- a5/O3,,Cbettu-ery) - 4�.a 55) • to&,,y-,\,,,c&N.Q. Rok m om. G-tA.x Ve to g,, ,crk,: a i rik. .\3\. 11-+ 0 irk, g>1. ' i '' Sk. +0, QA-cOla-c., Patri1 (ILI loao DNA_ Insurance("ertiilrata at: "�" � �-��-------.-. ,.-...-�......__..� Jac Name and Contact information of it crier° __ MT): '-- ~ 5 1�99( �� �F�tior'8 I�st9e. ♦,:9 �:�_,..__. ., _._.__..... Ilis Safe p• — -- Name of Competent� ��n����Otif[L 7.Q odC3'' i E i 5�� ..._...___ . of) k CCUVYNaX-a,,, t of 2 nnxsvc.W(Yat'r.X •cm+[ii�evy�awg5v0ysae,...ffaianeeK.,.. r e,...eurmm- 'dl. .d'2 YFG^ .:....S..2+ AWZ :A53 ilfeWA yG;k' K...1. JOL§?A' _T.Y1L'353ar,:: 4+:=i' 'SM25.f.S�72.11:^E:: • MattatItatteits Heittiog Lirerme i FT ..a:, cY, I L BY SIGNING THIS FO".,,ii, THE APPLICANT, OWNE AND EXCAVAT F'R ALL AC. O i'L-WF E AND CYRTIE TRAY THEY RE FAMIL, wrni,OR BEFORE COMMENCEMENT OF THE WORK,WILL BECOME IrAM IAR ALL LAWS A k Jt REGULATIONS A CABLE TO WORK PRO !r:.E r9 INCLU t;F G OSHA GULKFIOw G L. e, 82A, 526 CME 7.01 et ., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS .AND REGULATIONS AND THEY COVENANT AND AGREE T ALL WORK DONE UNDER THE PERMTT ISSUED FOR SUCH WORK COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CO ONS SET FORT BELOW. THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE : ' �,`r AN t Ts l EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO, FOR THE DURATION OF CONSTRUCTION, AUTHORIZES DULY APPOINTED BY THE MUNICIPALTrY TO ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CON THE CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS COVE^,'T`<G SUCH ORIL 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 TILE 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 : TAKEN BY THE MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAIL')11,'i°: COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED NECESSARY BY THE MUNICIPALITY. THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOINTLY A ND 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. C SIG NA DATE 8/1//(;11j EX AVATOR SI ATURE(IF DL'FERENT) DATE OWNER'S SIGNATURE{IF'DIFFERENT) _..__DATE: t y� E'er — k -ko, y.�,,,� .. „. • ,.1 L S!' . . f e ,... .ei'J"'dLn'1if .e.�„..w. -.... ......... ..3 2of2 . _ Town of Yarmouth DATE I'itpartment of Public Work,. '.,\f it Vit,1", ROAD ()PFNING PERMI1 Pursuant to the Town.of Yarmouth requirements and applicable provisions of Massachusetts eicnct:,1 Laws, the undersigned respectfully requests that your written consent be given to excavate and/or titoni:1 under the ground in the following Town/public/private way(s)for the following purposes: LOCATION: L--, w.y) LOTH: POLEH:_ PURPOSE: \ ta1\xti,ty)k.. 4 U mu\&yui \-tdea,Cc_raYketm;*-4-CAr b\rte..WITT„..V'c'( Proposed depth of cut: feet (NOTE:if rd.deeper cut is proposed, then you may also need to apply for a Trench Permit from the Yarmouth Building Department—see more below.) ti la tti The undersigned agrees to conform to all applicable federal,state,and local laws,by-laws,regulations (e.g.,OSHA),and guidelines,and to abide by all stipulations of and attachments to the Permit. In addition,the undersigned agrees by the acceptance of this Permit to: be responsible for all acts in connection with this Permit; have appropriate insurance coverage for any injuries to persons or property; indemnify the Town of Yarmouth for any of its acts in connection with this Permit; and,be responsible for trench excavation and maintenance during the period of construction as well as trench repairs caused by settlement and/or poor construction for a period of one year from the date of project completion. - , CONTRACTOR:"---).),„\t Sttte I 0 I CO- PHONE: 50 ?) (0-6(3.3‘ ADDRESS: CONTACT: h.0 0a3 ti k SIGNA PAVEMENT CUTS ALLOWED YES NO INFRARED FtE D YES NO SPECIAL CONDITIONS/A I-1 ACHMENTS: • IV) VONI,0 ( \ 713,02_to • Massachusetts State Law(MGL c.82A s.l and 520 CMIt.7.00 et seq) requires that an excavator obtain a"Trench Permit"from the Town of Yarmouth prior to digging a trench on public or private land or within public or private ways. A"trench" is defined in the regulations as"An excavation,which is narrow in relation to its length,made below the surface of the ground in excess of 3 feet and the depth of which is,in general,greater than the width,but the width of the trench,as measured at the bottom, is no greater than 15 feet." A trench permit application can be obtained at the Building Department located at the Yarmouth Town Offices at 1146 Route 28 in South Yarmouth. • All materials and construction methods shall meet Massachusetts Highway Department's Standard Specifications,as amended herein. • Permittee shall call DIGSAFE and the Yarmouth Water Division(508- '771-7921)at !cast /2 hours prior to initiating any work. • Only one half of the road may be closed al any one time,at least one travel lane shall remain open to traffic flow,and adequate police direction(paid by Permittee)shall be provided. Continued next page. I of 2 467 Wareham Street ±#, :'<!- Middleboro MA 02346 Phone: (508)923-6022 Fax: (508)923-6023 www.BayStatePiping.com NOTICE OF EXCAVATION REQUEST FOR MARK OUT OF TOWN UTILITIES To: Yarmouth Highway Dept From: Dawn Prunier Yarmouth Water Dept Fax: 508-775-9477 Date: 8-4-22 508-771-7998 ❑ TELEPHONE WORK ❑ WATER MAIN ❑ GAS PITS&PIPING ❑ WATER SERVICE ❑ GAS SERVICE ® ELECTRIC ESTIMATED INSTALLATION 8/10/22 DATE: LOCATION: Gunwale Rd—working from electric PMH 25/030 (located between houses 49 & 55) going down Gunwale to Eileen St—going right on Eileen St to elec PMH 24/020 (located between houses 67 & 110) TYPE OF WORK: Installing electric conduit via horizontal directional drilling for Eversource DEPTH OF WORK: 12' EXTENT OF WORK: Street and shoulder TOWN: Yarmouth JOB FOREMAN: Kathy Bertolino 617-921-4569 IDENTIFICATION: (DIG SAFE#) 20223111845—GunwaIe Rd & intersection 20223111859—Eileen St Area is premarked NEAREST CROSS STREETS: Eileen Stf,Pompano Rd Any questions concerning this excavation please contact job foreman as listed, all necessary permits will be applied for inyerson. • CERTIFICATE �J ' LIABIILI "Y I SURANN!�s : ` ' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CER I IF IC A t E HOLDER. Out, CERTIFICATE DOES NOT.AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY HE.POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTLION.1717,D REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be eiiclorsscd. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. ^ ct tomont on this certificate dons not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Lindsay Raffacl DeSanctis Insurance Agency,Inc. PHONE FAX 100 Unicorn Park Drive (Arc,No,Ext):(781)569-0'l20 I(A/C,No): Woburn,MA 01801 nooR!Ess:Iraffael@desanctisins.com INSURER(S)AFFORDING COVERAGE NAIC V INSURER A:The Travelers Indemnity Company 25658 INSURED INSURER B:The Charter Oak Fire Insurance Company 25615 Bay State Piping Co.,Inc. INSURER C:North River Insurance Company 21105 467 Wareham Street INSURER a:The Travelers Indemnity Company of Connecticut 25682 Middleboro,MA 02346 INSURER E:The Travelers Indemnity Company of America 25666 INSURER F:Nautilus Insurance Company ___•17370 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WI-IICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS._ INSR TYPE OF INSURANCE ADOL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVp (MM/DDIYYYYI IMMIODfYYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR DTC03E903048IND22 5/1/2022 5/1/2023 DAMAGE TO RENTED 300,000 PREMISES(Ea occurrence) $ X Limited Pollution MED EXP(Any one person) $ 15,000 X XCU PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,400,000 -POLICY X 78T LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ X ANY AUTO 8109M4538962226G 5/1/2022 5/1/2023 BODILY INJURY(Perpprsonl $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY _____ AUTOS-0 ONLY (Per accident) $ $ C UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 8,000,000 X EXCESS LIAR - CLAIMS-MADE 5821188453 5/1/2022 5/1/2023 AGGREGATE $ 8,000,000 DED X RETENTION$ 0 $ D WORKERS OYOERS'LIABILITY YINX PER ERH ANY PROPRIETORIPARTNER/EXECUTIVE UB4K29745A2226G 5/1/2022 5/1/2023 E L.EACH ACCIDENT $ 1,000,000 OFFICER/MEn NHR EXCLUDED? N NIA 1,000,000 E.L.DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below If yes,describe under 1,000,000 E.L.DISEASE-POLICY LIMIT $ E Equipment Floater 0T6607N943897TIA22 5/1/2022 5/1/2023 Deduct 1,000 F Pollution/Profess CPP203025411 10/7/2021 10/7/2022 Occur/Aggregate 2,000,000 DESCRIPTION OF OPERATIONS r LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) PROJECT:Various Trench and Street Opening ermits --- CERTIFICATE HOLDER _...__......_..._.._.___.__..------_---.----_-.--• CANC:EL.I;_ATION.._...._._.--.- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE i ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. 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