HomeMy WebLinkAboutBLDTR-23-000958 /r)a.4 leot_
TOWN OF YARMOUTH
BUILDING DEPARTMENT Permit Number 6/A)77,-
1146 Route 28, South Yarmouth, NIA 02664
508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued i4 6 0 951F
Expiration Date Ct.-#:716114
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$50.00
TRENCH PERNIIT
Pursuant to G.L. c. 82A *1 and 520 CNIR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Native of A,p Oise nt ci \ c c•t\,c\r',r.-- Phone Cell
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Street Address
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City/Town MA ZIP
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Name of Excavator(if different from applicant) Phone Cell
Street Address
City/Town I MA ZIP
Name of Ortneris)of Property Phone Cell
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Street Address
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Other Contact 1 Permit Fee Received No( ) Yes
Description,locadon and purpooe of proposed trench:
Please describe the exact kacation of the proposed trench sod its purpose(includes description of what is(or is intended)to
be laid in proposed trench leg;pipes/cable lines etc..)Please use reverse dde if additional space ra needed.
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RECEIV ; D
AUG 19 2022
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N arm and Contact Information of Insurer: a„, _rry,,_„,(•\ , -2,=1-, -(
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iNiacz F4pintion Date:
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:*4 sine of Competent Person las defined by 520('Me 7 el):
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License Grade: DP-i; Expire:km Date:
BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF THE WORK, WILL BECOME FAMILIAR
WrrH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,
G.L. e. lk 520 CMR 7.0$ 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 0 . ' AND ALSO, FOR THE
DURATION OF CONSTRUCTION, AUTHORI7ES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND IN CT 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,
/NCLUDING BUT NOT LIMITED TO ENFORCING THE REQV ' 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,
INDEM1•11TY, AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM
ANY AND ALL LIABILITY, CAUSES OR ACTION, COSTS, AND • SES 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 SIGNA7IRE
- DATE
EXCAVATOR SIGNATURE (IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DAIE:
F Of L'IlliTrneas Owl- wriis thrn.
POMO AleliOVED BY re*
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