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Home My WebLink AboutBLDTR-23-002966 inii.. lr#t ,ilk «7 g Xq,� TOWN OF ARMOUTH �* 0 BUILDING DEPARTMENT Permit Number &-b 7 ' 013_ e � 13t 7 jam; 1146 Route 28. South Yarmouth. MA 02664 a, , Date Issued �` `�Cv(► » ��•'_ ' 508-398-2231 ext. 261 Fax 508-398-0836 Expiration Date RED_EIVED TRENCH PERMIT !INOV 28 2022 i ,,}}� Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as 1gnfigtiBy. G DEPARTMENT THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSJDERATIO ____________ Name of Applicant Ellis broilvrj' Colip- Phone Cell Street Address QL 3 �. /� 'h ter CitylTown / MA � �'a r o J frl/' i O o4 ` 5 Nadk of Excavator(if d1ffNrent from applicant) Phone Cell Street Address City)Town MA ZIP i Name of Owner(s)of Property Street Address L tie k 6 Cell tdivi (V-' 696 — 9-9 8-) lag L-e1/4*-1S CitylTown MA I ZIP 1 e&1-- — °'a 6 7 3 Other Conte L 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. Sri C- Sys Insurance Certificate IS: w c L _ s o° acv'G 7c 6 9.04994 Name and Contact Information of Insurer: q,5.Scc ii¢- IF ) d (n su rvic t -- Policy Expiration Date: la 3 013 Dig Safe#: o c9 `7' su cf ?5- Name of Competent Person(as defined by 520 CMR 7.02): - ot-ary We 1of2 Massachusetts Hoistiu8 License 0 _ 6456 73 • 1 tT 130 i 01° License Grads H —a(}- Iz.i(: vG-/Y- Expiration Date 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. 82A, 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 IIMREWITH,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 THE MUNICIPALITY. 1'HE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND, INDEMNIFY, AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYERS 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 SI ATURE ? 1 C- 7 DATE r� EXCAVATOR SIGNATURE(IF EFFERENT) DATE OWNER'S SIG DIFFE Q DATE: 4_ PERMIT 1PPRO%EDsti ! s 11 PEIL TMNG.AUTHORITY' Tate CONDITIONS OF aPPRO%.�I. - i -^ 2of2 p Commonwealth of Massachusetts Division of Professional Licensure Hois iti l eer i, HE-028673 spires: 12/30/2022 LAURENCE F)ELLIS JR 8 NORTH STt DENNIS PORTiMA 02639 e 5ilt�..1.ti� Commissioner c fi: &nch& 4 Hoisting Engineer Restricted HE-2A-Excto:avators Inca:AZ DIGCall Center.(88g ccident call: (508) 71 Contact OPSI:(617)727-3200 or visit .mass,gov/dpl/opsi - ACOR J CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/16/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED 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 endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: RogersGray, Inc.-Kingston Branch PHONE FAX 63 Smith Lane (Am.No.Ext):508-746-3311 (Nc,No):877-816-2156 E4AAIKingston MA 02364 ADDRESS: mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Associated Employers Insurance 11104 INSURED REID&LA-01 INSURER B:West American Insurance Co 44393 Reid&Laurence Ellis dba Ellis Brothers Construction 23 Enterprise Rd, P.O.Box 59 INSURER c:Arbella Protection 41360 Yarmouthport MA 02675 INSURER 0: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2021067994 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 WHICH 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 OP INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITSLTR INSR WVD POLiCYNUMBER (MMIDD/YYYY) (MM/DD/YYYY) B X COMMERCIAL GENERAL LIABILITY BKW58371201 3/1/2022 3/1/2023 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $100,000 MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ C AUTOMOBILE LIABILITY 1020002607 6/9/2022 6/9/2023 COMBINEDent ccid SINGLE LIMIT $ (Ea a ) ANY AUTO BODILY INJURY(Per person) $250,000 OWNED X SCHEDULED BODILY INJURY(Per accident) $500,000 AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $100,000 AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WCC-500-5000706-2022A 12/3/2022 12/3/2023 X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N ANYPROPRIETOR(PARTNERIEXECUTIVE E.L.EACH ACCIDENT $100,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS(LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth 1146 Route 28 AU D REPRESENTATIVE South Yarmouth MA 02664 owszi 01988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD