HomeMy WebLinkAboutBLDTR-23-003198 ov TOWN OF YARMOUTH
' BUILDING DEPARTMENT Permit Number 6!'J E,2,3
lot .'_ y 1146 Route 28, South Yarmouth, MA 02664
\�'' MATT0. _s4 �t)$-39$- Fax ,tta-398-Ufs 6 Date Issued 0/).3/gam
5,�• 2231 ext. 261 F
Expiration Date ef.di DA53/49
5-i9 00'
RECEIVED
TRENCH PERMIT
Pursuant to O.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amen d9EC 0 9 2022
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATIDNI i_Dt NG DEPARTMENT
Name of Applicant Phone Cell . 3
�dd" 3 �CD. �'�C ,�-`/�-�j7 r -a/2- Nam/
Street Address 36
3 111�lieS fQ )_
City/Town MA ZIP
Name of Excavator(if different from applicant) Phone Cell
Street Address
City/Town MA ZIP
Name of Owner(s)of Property Q.)414 (igh//t' Phone Cell,n-6q/J G/y(/
Street Address 786 77''��
City/Town MA i ZIP
u ail- t es)6y
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(eg;pipes/cable lines etc..)Please use reverse side if additional space is needed.
5 // ffscn. 1/64-/- yea
Insurance Certificate#:cm.130 iza8 222
Name and Contact Information of Insurer:/ 14//174e-10,//1846e-
! �Gbe ,1/1v��'/1a / /yam r/174� -
Policy Expiration Date: /6207
Dig Safe It: Q02:2//9D
IName of Competent Person(as defined by 520 CMR 7.02):
LVi114 Chb:9 lei
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Massachusetts Hoisting License# H/)3y5-6
License Grade: L '0?/4 Expiration Date: 3/2`/2
17/
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 GOVERING 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.
APPLI GN T'U Q 20.rJ
DATE 6 q�/
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OW 'R'S S G TU (IF FERENT)
DATE: 12- 12
Fir CIFtn€u use--1 not write in this'swim.
PERMIT APPROVED DV $ Ap tint Fee...
PERMITTINGAUTIIOIU •
CONDITIONS OF APPROVAL.
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