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HomeMy WebLinkAboutBLDTR-23-003207 'Thu JL / /qM? .ri TOWN OF YARNI()UTH o BUILDING DEPARTMENT Permit Number ai iy 1146 Route 28,South Yarmouth, NIA 02664 ko,rtrr. 508-398-2731 ext, 1261 Fax 508-398-0836 Date Issued 6© ,3 ex-) Expiration Date cY 13ozq $50. SO TRENCH PERMIT Pursuant to G.L. c. 82A*1 and 520 C'MR 7.00 et seq.(as amended) THLS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Nan of Applk*nt 6 3 6 rtar.ca,tc+.,F On 1At.. Phone Cell Street Address Sbg, till-obS.3 Clty/Town MA 711a So.nit4,0„. Ik,ko. 0Z5b3 Naves of Excavator.t it different from.pplkant# Phone Cell Street Address City/Town MA ZIP 1 - Name of Ownerts►of Property Af Shur Cell 0.<f Q,E{' Street Addreat I Ll C.hivnc Greer Cyr City/Town MA I ZIT Other Contact Permit Fee Received No Yes Dsuselption.iocatiaa and purpose of proposed trench: Please describe the meet location of the proposed trench sad its pawpaw(inehade a description hat itt be find In proposed trench ors;pipade hl lines etc..)Please um reverse side IPadditionSE Is of nee~ (or is in )to 1451-aN0. "pr Of << b�taw 6 d-box 0nt,L) Insurance t'rnii'kata Mt Name sad("orttart Inrnrmatir n of Insurer: R E-C-E L__�-.E D Se,lec,cur SAS. P ty iiii iratian t)rtr: Die Sett -- _ GE£-e 9- 022 1 it Li go938q *cone proms Pereoa ta.mined 11 sap C;ma 1az): gU14DING UENARTMBy NT Rdbtri- C,� ( of 2 • 2,4 I G ZA_ F p BY SIG FORM,THE APPLICANT,OWNEIL AND EXCAVATOR ALL ACKNOWLEDGE AND CEI TWY THAT THEY ARE FAMILIAR W TII.OR BEFORE ENC Of TIM WORK,WILL BECOME FAMILIAR WITH,ALL LAWS REGULATIONS APPLIC WO PROPOSED,INCLUDINGREGULATIIONS, G.L. c. F2A, 528 CMR 7AOR art AND ANY CAELE MUNICIPALOsIDINAN $Y-L4 WS AND REGLIATKINS AND THEY COVENANT AND AG' A" T ALL WORK DONE UNDER*Mt PERMIT ISSUED FOR SUCH WORE WILL COmin..v THEREVVITH DI A FORTH BELOW. THE UNDERSIGNED OWNER AUTHORIZES APPLICANT TO APPLY FOR THE PERMIT AND TIIIB EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER. AND ALSO, FOR THE DURATION OF CONSTRUCTION, A t . PERSONS DULY ., e t : *> BY TIRE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONITOR AND Disnrcr THE WORE FOR CON/DIMITY WITH THE CONDIIIONS ATTACHED HERETO AND THE LAWS AND TvoNs GovERING SUCHW THE UND` ' :IGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO } • THE MUNICIPALITY FOR ANY AND ALL cons AND EICPENSES DICURIXED BY THE NIUNICIPAIIIIr IN CONNECTION WITH THIS rtramrr AND iWORKcomments nts THEREUNDER, INCLUDING SUT NU7 LIiMrreu TO ENFORCING nut OF STATIC LAW AND COPT0111014S OF ravi TT,'INSPECTIONS MADE TO ASSURE :[ MEASURES TAKEN BY THE S MI TO PROTECT THE PUBLIC WHERE'nut CANT OWNER OR EXCAVATOR HAS FAILED TO CONI1PLIt THEREWITH INCIAIDING POLICE $ t * _* L . DEEMED • RY BY THE MUNICIPALITY. UNDUSIGNIED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVISEALLY TO DEFEND, " r ,AND HOLD HARMLESS THE MUNICIPALITYALL OF ITS AGENTS AND EMPLNYEBII FROM ANY AND ALL LIASIUTY,CAUSES OR Arnett C f :+ ES RESULTINGFROM OR ARISING OUT OF Asy INJURY, DEATH, LOSS, OR DAMAGE TO A f OR PROPERTY THE WORK CONDIJCIMD UNDER TNIES putmrr. APPLI TSIGN RE I2(C1`21, DATE Iw XC VATO R IGNA TURE ill DOTE* I / DATE , tIWNER'S SIC„A'I`C.1 E LIP IFFE t"} �_..._ DA`TE: Per tisitoits e Do tot