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Permit Number �-.�3--
�- !.``p BUILDING DEPAR"I'NIEti"T �-.
1?-( e` 1146 Route 28. South Yarmouth. NIA 02664
- `i - �`�' Date Issued �� - �
508-398-2231 est. 261 Fax 5+08-398-0836 7
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Expiration Date aief
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RECEIVED
TRENCH PERMIT __--
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as a*ec d d 28 2022
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERA 'I DING DEPARTMENT
Name of Applicant Phone Cel 1l
Dig It Construction LLC 508-367-2256
Street Address 508-432-1635
22 Diamonds path / PO box 268
City/Town MA I ZIP
South Dennis i 02660
Name of Excavator(if different from applicant) Phone Cell
Street Address
City/Town MA ZIP
Name of Owner(s)of roperty Phone Ceil
eot c rbwoks
Street Address Sam - 400 -a3 bs
Po (3ox 116-
CitylTown MA ZIP
AV. flarshgela OaosI
Other Contact 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 teg;pipeslcable lines etc..)Please use reverse side if additional space is needed.
LI I 0-1A C b ber-13
new 5e 4l'
Insurance Certificate#: ZDNJ017376
Name and Contact Information of Insurer:
Eastern states Insurance - 781-642-9000
Policy Expiration Date: 5/18/23 _
Dig Safe#: 0/092- 3(.0 1-1 9$
Name of Competent Person(as defined by 520 CMR 7.02):
Kerry Sullivan
Massachusetts Hoisting License# H E-153873
H E-2A 2/24/24
License Gam: _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,
CL. 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 THEREWITH,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.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND 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.
APPLICANT SIGNATURE
DATE I1lag
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
' _A (IF DIFFERENT)
r;� DATE: 11! -b 2
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