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HomeMy WebLinkAboutBLDTR-23-000960 in ZL' j'ete 5'1 Z3/22- : i. TO%%N OF l :ARi Ot'TN `gyp BUILDING DEPARTMENT Permit Number JSL �-23— k ` 1c` 1146 Route 28. South Yarmouth. NIA 02664 �� � `� '� Date Issued 1�0oq(t�l� a�Y' n ,4,�' 508-398-2231 ext. 261 Fax 508-398-0836 Expiration Date e 91--i/ . ' RECEIVED 5—e: l?L) AU6 19 2Q2Z TRENCH PERMIT BUILD NG DEPART Cant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant ��"� ��YJ7 CS �E/vy �r��� Cell s 6 Street Address 3 6�3'7 _c - City/Town MA I ZIP a�i I L 47S me of Excavator(if different from applicant) Phone Cell Street Address City/Town MA ZIP , I Name of Owner(s)of Property Phone Cell Street Address 1„q r 1.*€, l��Z�ei'9I C� '' Iil S+Ned City/Town MA I ZIP 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 purpose(include a description of what is(or is intended)to be laid in proposed trench(eg:pipes/cable lines etc..)Please use reverse side if additional space is needed. SeptG U`c S iInsurance Certificate#: �© .:Vl C -' 500 06 -gbg11- Name and Contact Information of Insurer: 4556CI r` W ( '-A 11� ►,_C41 Co ' Policy Expiration Date: Dig Safe it: o' .2` 3 a o &-9 Name of Competent Person ins defined by 520 CMR 7.02): I 1.,,,,, "Ill J 1 of 2 Massachusetts Hoisting License It ( —+ /3 License Grade: ti M/4 _ Expiration Date: I I ' r2 O?2- 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. 82A, 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 GOVERING 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 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 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 SIGNATURE 7 DATE - 0 02 EXCAVATOR SIGNATURE(IF DIFFERENT) DATE OWNER'S SIGNATURE(IF DIFFERENT) DATE: 7 /3 - L)), For ciN/I uvi a uw—Dt:lied*rite in thi% ' ? PERMIT 1I'Piti)%I D HI _ S. ApplEatEnn For PERM MINI:.itTHORIry Date ('t1NDtI )N1(1E'aI'PitU�AL 2of2 1 A; •es ,1 . t r i e' , -, , — Commonwealth of Massachusetts i 1 1, • Division of Professional Licensure . Itilf - . Hats* Igtbirr ...--' --- i- ., • . HE-028673 ...... —--h-----1 6,ires:12/30/2022 LAURENCE I5ELUS im4,, :7-. 8 NORTH ST:!1 DENNIS PORP,HIA 02111! :::' .v.-- . Commissioner dae2n. K Fi&ncrua., . . . .., , Hoisting E - Restricted to: ngineer HE- .Excavators DIG SAFE Contact 041:(6/7)727-3a2OlienCeetocar vilis:It(5"82"444 www :ma rov dpt/opsi case of accid nten(88e)3447233ss.g ., 4.... ® ACCORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM1DDlYYYY) 12/13/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT RogersGray, Inc.-Kingston Branch PHONE FAX 63 Smith Lane (A/C.No.Ext):508-746-3311 — 1(A/c,No):877-816-2156 Kingston MA 02364 E-MAIL og g y ADDDRERE SS: mail r erS ra .COm INSURER(S)AFFORDING COVERAGE NAIL# INSURER A:West American Insurance Company 44393 INSURED REID&LA-01 INSURER B:Arbella Protection Insurance Company,Inc. 41360 Reid&Laurence Ellis dba Ellis Brothers Construction 23 Enterprise Rd, P.O.Box 59 INSURERC:Associated Employers Insurance Company 11104 Yarmouthport MA 02675 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2114965942 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR{ TYPE OF INSURANCE ADDL SUER POLICY EFF POUCY EXP LTR ,INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) WETS A X 1 COMMERCIAL GENERALLJABILITY BKW58371201 3/1/2021 3/1/2022 EACH OCCURRENCE $1,000,000 I DAMAGE To NTED CLAIMS-MADE I X I OCCUR PREMISES(Ea occurrence) $100,000 MED EXP(My one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE S 2,000,000 X POLICY JE(° LOC PRODUCTS-COMP/OP AGG $2,000,000 i OTHER: $ B AUTOMOBILE LIABILITY I 1020002607 6/9/2021 6/9/2022 EO aBBINEntSINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $250,000 OWNED SCHEDULED I AUTOS ONLY AUTOS BODILY INJURY(Per accident) $500,000 X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $100,000 $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE i AGGREGATE S DED I (RETENTION$ C WORKERS COMPENSATION WCC-500-5000706-2021A 12/3/2021 17/3/2022 $ AND EMPLOYERS'LABILITY YIN STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $100,000 OFFICER/MEMBER EXCLUDED? ( J N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE.POLICY LIMIT $500,000 I DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate holder is listed as additional insured under General Liability for on-going operations when required by written contract or agreement. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POUCY PROVISIONS, 1146 Route 28 South Yarmouth MA 02664 ALIT ,...D.REPRESENTATIVE I IP.........../""-row,",mo. fret 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD