HomeMy WebLinkAboutBLDTR-22-000313 iri
„u TOWN OF YARMOUTH C�I /zd/z�
°T•Y` ,1
,r'� o BUIL.DINC DEPARTMENT Permit Number s n �
of 1146 Route. 28,South Yarmouth, MA 02664 _t4 M,�A S 4 ' 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued 3
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Expiration Date G # .qI bilk'
$5000
TRENCH PERMIT
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(rors amended)
rins PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of.tpplkant b 116 cu.c.o c\- f\ tilc. Phone Cell
Street Address
3�-Lt koa , ao .., S G$ OAS 3
City/Town i MA ZIP
Sotrvdvo,d,, U/S 4,3
Nein*of Excavator tit different from applicant) Phone Cell
Street Address
City/Town MA ZIP
Neale of Ownerts of Property Nali(15 Phone Cep
Street Address 1( A(co k1h a Qcwc,
Cky/Town 1 MA I ZIP
9c rt o>4
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 pupate(Include a descripthue of what is(orris intended)to
be laid in proposed trench tee;pipes/cattle lines etc--Please use reverse.ride it additional space is needed.
( 1 r\SkG\1 c o l 0-C- Ss). etc, S S- t on
' RECEIVED
J 21 2022
Insurance t'ertifkat.d= 523981 81
RUILRENG.DE ARTMENT
Name and Contact Information of Insurer: By -
JQleC - w tnS,
Policy Etpirstto n Dow 5 I t 2,3
nlaS.teO: 2. 0 22290 32$q
1 :Name of Competent Person Iris defined by 5211(Mit 7.02):
&obi (411
I of 2
R4aaachusetts Hoisting License I HE • 04 81}0
•
Lire:tie Grades 24, Expiration Date: 2( 29
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. a 92A, 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 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 FAMED 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.
&PPLICr T SI ATURE
"" ✓ DATE 20 22
ll EXCAVATOR IGNATURE ILF DIE l ERENT)
DATE
OWNER'S SIGNATURE UIF DIFFERENT)
DATE:
ra r ripe o=ve+MAR rii• die
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