HomeMy WebLinkAboutBLDTR-23-000312 f? a/I/ A 7 /
TOWN OF YARMOUTH r ,
0. BUILDING DEPARTMENT Permit Number //3 b7 -
AI Cr 1146 Route 28,South Yarmouth, MA 02664
E' $08-398-2231 ext. 1261 Fax$98-i s os36 Date Issued 6 6 6 3/2-
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Expiration Date (1 r gdolligi2_
$50.00
TRENCH PERMIT
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
rHLS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONsimFRAnoN
Name of.4ppikant 4$(j cut co.\) -k\o n liic. Phone Ceti
Street Address �o 1 b S 4 6 8' "-1 - O(S 3
3'1-4Citylrown MA ' Z12
So rXWO,(An 02S�3
Name of Excavator of different From applicant) Phone Cell
Street Address
Citylrown MA ZIP
Name of Ownerisi of Property Sande a, k u"a done Cell
Street Address `3. 31-R. ($'C
(03 (oocc}on
Cby/Towet MA 1 ZIP
Other Contact [Perm Fee Received No( ) Yea(
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 for is intended)to
be laid in proposed trench(es;pipes/cattle lines eft..)Please use reverse side if additional space Is needed.
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RECEIVED
insurarnre Certitkatx r: Jlll. 2 2022
S/3981-81.
Name sad Contort Information of Insurer BUILDING GE+1ARTMEPi r
By
Pocky Fvpiration Date: 5 (t(2,3
Di*Sat.I.:
LC) tt 0 5(.511
Yarns of Competent Person to refined hy S:A C'\IR 7.t12):
Iot2
Nf*a thuset,a Hoisting License I
HE • O NBi-to
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I
Lkenee Grades 2 Expiration Date: 2(1+t
2,4
BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF THE WORE,WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,
G.L c. S2A, 521/ CMR 7.01 et seg., 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 WTTH 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 nix 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 Or 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 HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND
ANY AND ALL LIABILITY,CAUSES OR ACTION. COSTS, AND EXPENSES RESULTING FROM��Y FROM
Or ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY OR ARISING OUT
CONDUCTED UNDER THIS PERMIT. DURING THE WORK
APPLIC T SI TORE
`i DATE ZU ZZ
64,1
EXCA ATOR IGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
Far I. -Pe met'rift M all
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