HomeMy WebLinkAboutBLDTR-23-000318 piC,i iefiL. 7J lgd-
�, TOWN OF YARMOUTH
4 '4a BUILDING DEPARTMENT Permit Number / ;7 -:,2 3
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y 1146 Route 28,South Yarmouth, MA 02664
� (, $' 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued .3/K
Expiration Date 0 ,d-q10/
0.00
RECEIVED
TRENCH PERMIT
Pursuant to G.L. c. 82A *1 and 520 CMR 7.00 et seq.(as ante de dd-JUL 15 2022
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
BUILDING DEPARTMENT
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City/Town MA ZIP
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Naas of Excavator(if different from applicant) Phone Cell
Street Address yy set m-E-
Cityfrown MA ZIP
Name of Owner(s)of Property 4.kite �1 c t(z Phone Cell
Street Address
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Cityffown MA ZIP
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Other Contact I Permit Fee Received No( ) Yes(t
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(ce;pipea/eabie lines etc..)Please use reverse side if addklond space is needed.
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Insurance Certifkate If:
Maine and Contact information of insurers-
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Polley Eeplratiaa Dote I -
Name of Competent Person fee defined by S2ti CMR 7.1123:
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BY SIGNING THIS FORM.THE APPLICANT,OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTW
THAT TREY 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 I.. EPA, 520 CMR 7.01 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 WORE ON THE PROPERTY OF THE OWNER, AND ALSO, FOR THE
DURATION OF CONSTRUC LION. 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 CONS 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
TRS PERMIT,ACTIONS 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 HOW HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM
ANY AND ALL LIABILITY,CAUSES OR ACTION,COSTS.AND EXPENSES RESULTS FROM OR ARISING OUT
OF ANY INJURY. DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNATURE
DATE
EXCAVATOR SIGNATURE CIF DIFFERENT)
DATE
SOW YE SIGNATURE(IF DIFFERENT)
7/14/2022
DATE:
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