HomeMy WebLinkAboutBLDTR-23-000957 „, oT•Yq ,
TOWN OF YARMOUTH �t k d ��' 3%Z
So BUILDING DEPARTMENT Permit Number 7p 7 _
O( - dior ,s y 1146 Route 28,South Yarmouth, MA 02664
{�v 7,„ „ ,41” S08-398-2231 ext. 1261 fax 508-398-0836 Date Issue,� /�d� 5 '7
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RECEIVED Expiration Date 0,tt4 / 56
AUG 19 2022 $50.00
BUILDING DEPARTMENT TRENCH PERMIT
BY.
`Pursuant to G.L.c. 82A *t and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Naar of.(ppikant 0; 17 Phone Cell
Street Address
PC) 0 72b
City/Town, i� I,_ MA ZIP
Name of Excavator Of different from applicant) Phone
Cell
Street Address,
CityfTown i MA I ZIP
Name of Ownerts)of Property Phone
Cell
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Street Address Pc,
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City/Town MA I ZIP
Other Contact ( Permit Fee Received No( Yes
Description.facade.and purpose of proposed trench: 1 ( )
Please describe the exact of the proposed trench and its purpose(include a deseripdeu of what is(or is intended)to
be laid in es;pipes/cable Hoes etc..)Please use reverse vide if additional space is needed.
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Insursnc,Certifkats i
Name and Contact Information of Insurer:
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Polley Expiration Date: d i a� mac/ .., A
Die Safe If: 0,3) , 32)- 9/1
( Name of Competent Person tas defined by 520('M 702):
l o.5W 1
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Massachusetts Hoisting License Y F- 0.5 I /
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License Grades )C /ci` Expiration Date: U`/ .2 6)C j
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 WORE PROPOSED,INCLUDING OSHA REGULATIONS,
G.L. c. EUA, 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 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 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
DATE /4 g 020 a"�
7
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGNA-L7 DIFFERENT) •
DATE:
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