HomeMy WebLinkAboutBLDTR-23-003212 in (5_1 kt/g/27_
o�,yAR�4 TOWN OF YARMOUTH
• o , BUILDING DEPARTMENT Permit Number ,5L p7-e_g _
y 1146 Route 28,South Yarmouth,MA 02664
„ 1:TAC s,� 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued G5 .,.-/e-
Expiration Date ('ezill g(p r
$50.00
TRENCH PERMIT
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant - Phone Cell
Street Address
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- > OY�,„ Email Address:L c® "\@Qotic-vc1excc -�,cAuc:,ct%
City/Town MA ZIP
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Name of Excavator(if different from applicant) Phone Cell
Street Address
Email Address:
City/rown MA ZIP
Name of Ownerls)of Property Phone_, Cell
Street Address
cabE\St.,&e Email Address:
City/Town MA ZIP
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 tide if additional space is needed.
..RECE1VEL
)C "M DEC 09 2022
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BUILDING DEPARTMENT
Insurance Certificate M:
Name and Contact Information of Insurer:
Policy Expiration Date: ', I I7,1 1.01..
Dig Safe Il:
Name of Competent Person I as defined by 520 CMR 7.02):
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Liam*Crean twu hate: 'ii I 44L
SY SANG THIS FORK.THE APPLICANT,OWNER AND EXCAVATOR ALL ACKNOWLEDGE AND CF.t[DIi•Y
THAT TREY ARE FAMILIAR WTTDD,OR,BEFORE COMMENCEMENT OF THF.WORK.WILL BECOME FANDL AR
WITH,ALL LAW AND MGM-ATOM APPLICABLE TO WORK PROPOSED.INCLUDING OSHA MLGU AUONS,
co_ c 12A. S20 CMI 7.14 et seq., AND ANY APPLICABLE MUNICWAL ORDINANCES, BY-LAWS AND
RECULATIC'1NNS AND TREY COVENANT 4ND AGRET THAT ILL WORK DONE UM/ER THE?ERMfl mum FCHI
SO( WORK WILL COMPLY THERVWTTR IN ALL RESPECTS AND WITH THE CONDTTDONS SET FORTH
BELOW.
THE V'ND€RSIC NED OWNER ALTI0ORLMS THE .APPLICANT TO APPLY FOR THE PERMIT AND TUE
EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF TEE OWNEJL AND AI SO, FOR THE
DURATION OF CONSTRUCTION, AUTHORIZES P'E; 5 DULY APPOINTED EY THE ML'Mt1PALI TY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CO'.ITHLNIIT1' WTT'II THE
CONDITIONS ATTACHED HERETO AND TILE LAWS AND RECCLATION S COVERING SUCH WORK.
THE U 1)EHS1GNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REIMBURSE TILE MUNICIPALITY FOR ANY AND ALL COSTS AND 1017ENSES INCL RRED RY THE
MUNICIPALITY DI CO NEC ION WITH THIS PERMIT A I Tlx:WORK CONDUCTED THEREUNDER..
'NCI—UD1N4..am NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AM)CONDITIONS S OF
THIS PERMIT.INSPECTIONS MADE Ti)A RE COMPLIANCE THEREWITH,AND MEASURES TAKEN BY THE
MLNiCDPALITY TO PROTECT THE FVBUC WHERE TUE APPLICANT OWNER OR E XCAYATOR HAS FAILED TO
COMELY THEREWITH INCU.DING POLICE DETAILS AND OTHER REMEDIAL MEASLRES DEEMED
NECESSARY BY THE MUNiCIPALDTY.
inf.UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND.
INM'EEMNIFY,AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF TIN AGENTS AND EMPLOYEES FROM
ANY AND AU LIABI.LIFY.CAUSES OR ACTION,CIOST4,AND EXPENSES RESULTING FROM OR AR1SJN G our
Of ANY MIRE. DEATH. LOW OR DAMAGE TO ANY PERSON OR PROPERTY D)URINC TILE WORK
CONDUCTED UNDER Taos PERMIT.
*MECUM SIGNATURE
DATE \,Z\.,
EXCAVATOR SIGNATURE OF DIFFEREWI)
DATE
OWNER'S SIGNATURE 41P OPTERF.NT I „
Fier IPSO alert+*I ad WIMP a Ili liir rselie�t
I1Y 1 _ Ft*
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t'.ON O®APPHOVAL
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