HomeMy WebLinkAboutBLDTR-23-002932 _ in 0.-1 lel /i/0)--9 J4)9_
TOWN OF YARNIOLITI I
BUILDING DEPARTMENT Permit Number 8CO7E —
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c.:) .. . .i...“ 1146 Route 23, South N artnoutb, NIA li 664
Date Issued ot---3 mad 4,32
'''.,4Q5\ -!,'"".'„Sts.'-. :A3-398-2231 ext. 261 Fax .50S-39S-0836
Expiration Date
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TRENCH PERMIT IRECEIVED
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et sey.(as arnefided)
THLS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDF.RATI )N NOV 29 2022
Name of Applicant. - Phone
c 1 BUILDING uLvARTMEN—
V.ACVCV3 EY•C-CNV-A\CX\ By
Street Addregg
'lk • () (C?)C 5c-\c'City/Town MA I-ZIP -----
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Name of Excavator(if different from applicant) Phone Cell
Street Address
City/Town MA i ZIP
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Name of Owner(s)of Property 0\\\v....2c\'-' (...,3A\./..,‘ Phone Cell
Street Address 5U-6- 5S— s5-2.3
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City/Town MA IZIP
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Other Contact Permit Fee Received No( ) Yes( 1
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.
Insurance Certificate#:co,2233,t
[ Name and Contact Information of Insurer:
506-1 \(\e'N_C.,,NcV-2,1,)< 6.k -"rm.-Viz-0
Policy Expiration Date: 5 vik-u.)-i:
Ci Dig Safe#:
1,C.5t2..1:AS 03C1 LAC'\ —
Name of Competent Person(as defined by 520 CMR 7.02):
..___ \M cy\%.e, We-\c\c\ . _ .. ___
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Massachusetts Hoi Ling License# pt 4 5 !
License Grade:
Ex iration Date: 1 CO I LUZ
BY SIGNING THIS FORM. THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE
TWITH,HAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF THE WO AND CERTIFY
ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED, ' FILL BECOME REGULATIONS,
c. A, 520 CMR 7.00 et fNCLUDING OSHA REGULATIONS,
REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE THE PERMIT
SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS ANDORDINANCES,APPLICABLE MUNICIPAL BY-LAWS AND
BELOW. wlTit THE CONDITIONS SET ISSUED TH
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND T
EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO, ILE
DURATION OF CONSTRUCTION, AUTHORIZES PERSONS DULY , FOR TILEO
ENTER UPON THE PROPERTY TO MONITORAPPOINTED BY THE MUNICIPALITY TO
CONDITIONS ATTACHED HERETO AND THE LAWS ANDREGULATIONS COVERING SUCH WORK.CT TRE WORK FOR CONFORMITY WITHTHE
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED
MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED BY THE
INCLUDING BUT NOT LIMITED TO ENFORCING THE THEREUNDER,
CO DER,
THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCETHEREWITH,
REQUIREMENTS OF STATE LAW AND CONDITIONS OF
MUNICIPALITY TO PROTECT{tom PUBLIC WHERE THE APPLICANTWNE OR ND MEASURES
HAS FAILED TO
COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED
NECESSARY BY THE MUNICIPALITY,
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOLNT Y AND SEVERALLY TO DEFEND.
INDEMNIFY, AND HOLD HARMLESS TILE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYER FROM
ANY AND ALL LIABILITY, CAUSES OR ACTION, COSTS, AND EXPENSES RESULTING FROM OR ARI.SIN FRUT
DU
OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY OUT
CONDUCTED UNDER THIS PERMIT. RfG THE WORK
APPLICANT SIGNATURE
DATE I 1 -1
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGN TUBE(IF DIFFERENT)
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