HomeMy WebLinkAboutBLDTR-23-002872 TOWN OF YARMOUTH ///i3iz7
BUILDING DEPARTMENT Permit Number / f)�7 _ 3--
0
04. �' y 1146 Route 28,South Yarmouth, MA 02664
508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued 90
Expiration Date &X-:1
$5000
RECEIVED
TRENCH PERMIT .__--.. ...
Pursuant to G.L.c. 82A §1 and 520 CMR 7.00 et seq.(as amegided)NOV 22 2022
THIS PZRMCT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATKINs U i L DI N U D t PARTM E NT
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Name°f Applicant PKM Contractors,Inc. Phone Cell
Street Address 508-385-5993 508-237-3328
313 Hokum Rock Road
City/Town MA ZIP
East Dennis MA 02641
Nsass of Excavator of different from app ) Phone CeJ
Street Address
Cityfl'own MA ZIP
Name of Ownerhs)°f Property Joao Pereira Phone Ce.
508-922-8149
Street Address 7 Saturn Lane
Ckyfl'own MA I ZIP
South Yarmouth MA I
02664
Other Contact I Permit Fee Received Not 1 Yes t )
Description.location and purpose of proposed trench:
Please describe the exact location of the proposed trench and its purpose f inch:de a description of what le f or le intended)to
be laid in proposed trench(ea;pipedesbie Haas etc-)Please use reverse side if additions space is needed.
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insurance Certificate N: 503-872657-2
saw and Contact information of Insurer
j Eastern States Insurance-Karen Cox 50 Prospect St.Waltham, MA. 781-642-9000
Policy Etpirstion J)ate 08/20/2023
DiH Safe/1: 2022-4609512
Name of Competent Perms vas defined by 520 CMQ 7.82):
Patrick K. McDowell
1 of 2
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Massachusetts Hoisting License I HE-039080
•
License Grade: HE-2A Expiration Date: 04/19/2024
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. S2A, S210 CMR 7.91 at 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 WTI I 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 WORE.
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
THUS 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 TIlE 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 GNATURE _.,,
• DATE 11/17/2022
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
2. /4/2.2. DATE: 11/17/2022
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