HomeMy WebLinkAboutBLDTR-23-002083 ma/ /O// //Z
TOWN OF YARNIOUTH
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Y��o' BUILDING DEPARTMENT Permit Number 6 0)7
11.46 Route 28,South Yarmouth, MA 02664
508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued 6 _d��
Expiration Date e. %kkU/61
$50.00
TRENCH PERMIT
Pursuant to G.L. e. 82A §1 and 520 CMR 7.00 et seq.(as amended)
Tim PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Nance 01 Applicant t-- 0 .-,5A-u 1 tC-) ;._ Phone Cell
Street Address 4 . 4..)Clk,sk f��c j°q• 1/8 J8� jo
City/Town MA ' ZIP
Name of Excavator(if different front applicant) Phone Cell
Street Address
City/Town MA ZIP
Nanye of Owners)of Property - Phone
Cell
Street Address :c3x q31 -36o '0?5a
City/Town MA ZIP
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Other Contact Permit Fee Received No( 1 Yes( ) -�-�
Description,location and purpose of proposed trench Kan n ('�' ^J Lr•• t'Ct'e .J�4 �jyy7
Please describe the exact location of the proposed tees its purpose(Tsai-rude a description of w aN f is(or is ini,mded)to
be laid In proposed trench(es;pipes/cabk lines etc..)Please use reverse side if additional space Is needed.
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'ARTMENT`ameand Contact Info Non of 17� ,/,02&_0>tiNA SL "'-C
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Policy Erpirsdon Date: -3 t 7 1,2 2 _
Dig Sale I: 0 y/0 /6
Nuns of Coro tent Person das defined by 52.0(MR 7.020:
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Massachusetts Hoisting License I /35 3,2 9 /
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' Lkense Grade: Q Ex 'ration Date:
BY SIGNING THIS FORM, THls 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. 824, 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 NW'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 HARM,NM 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 SIGNA
DATE Ay/74k"..
EXCA ATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
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