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Home My WebLink AboutBLDT-23-2109 Oli' Y AKMt�U'1 tl ° ,3l.07-Z 3 2f02. �,• BUILDING DEPARTMENT Permit Number 1146 Route 28.South Yarmouth,MA 02664 N MArrA„ sx 508-398-2231 ext.1261 Fax 508-398-0836 Date Issued Expiration Date 0 q qi) 00 RECEIVED TRENCH PERMIT .._.__ Pursuant to G.L. c.82A §1 and 520 CMR 7.00 et seq.(as amended) OCT 18 2023 THIS PERMff MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION IDINfl DFPARTMF_NT Name of Applicant e`")-ckvkl ., c+1Gc'• *'' Phone Cell Gas@. C.ed coepA c t v t �s^G' 33By "77. -a Street Addre t J C ra.6 Email Address:{T,G\ta t 9e.Ci\SC'pViC e5rtlaikiln CitylTown MA ZIP larrelooNh Name of Excavator(if different from applicant) Phone Cell Street Address Email Address: City/Town s MA ZIP Name of Ownerts)of Property Phone Cell moc rx-. t r1t). 7 Street Address \\ ? \eX t r Email Address: City/Town MA ZIP lGs-mooh G t Other Contact I 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 fez;pipestcabie lines etc..)Please use reverse side if additional space is needed. • insurance{Certificate pJOi1g0q)G(Pa V I Name and Contact information of Insurer: 00 29t A. 0' ,' Policy Expiration Date: )o l cli Dig,Safe It: Name of Competent Person(as defined by 520(MR 7,02):, c c,\ 1 of2 Name of Competent Person(as defined by 520 CMR 7.02): 9c i root-VA r Massachusetts Hoisting License# \. ('}C6LLC4 7 License Grade: \C c"4 Ex►iration Date: f'b' i j 7J 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 TIFF, 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 'CO ANY PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT. APPLICANT SIGNATURE DATE I //.1%. EXCAVATOR SIGNATURE(IF DIFFERENT) DATE OWNER'S SIGNATURE(IF DIFFERENT) DATE:_ '� ��&= 5w,^n..�s��zzog 3"Vi l: i-c-355 n�� 7-0 ifff2� at-:'al"� rvYaV.py„�a.'�Pfi -j r S M n6p� )3,0 arZk � 4,-q .CW: � 40 vA to .`i +T IZ 7'^"Tr•ery ` 4 'n:i' k4"t'A � , r . p p y Ac S i teC% . idlt 11* .i:. T ma IMrIGDGNiIYYYI AccoRd CERTIFICATE OF LIABILITY INSURANCE a(NO12023 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 poillcy(iss)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 r hts to the certlficato holder in lieu of such endorsements. PRODUCER NAIMEt Linda Sullivan THE HILB GROUP OF NEW ENGLAND Nl LLC PHONE,rgr 000057 4238.....,..-... _ _.. _ as, , Agss: Isuliivancorrs.corr 120 Tumplke Rd rrlsUREMAFFORDINCLCOVE RAGE _ _..._ RAMS Southborough MA 01772 INSURER A t TRAVELERS PROPERTY CAS CO OF AM 25874 ; INSURED INSURER Et: - __ ___,. �__ CAPE COD SEPTIC SERVICES INC INSURER CI „. _._ _ ...,____.._ __ INSURE 01 350 MAIN ST INSURER E s WEST YARMOUTH MA 02873 INSURER P COVERAGES CERTIFICATE NUMBER: 894678 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN 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 CLAIMSYTXP . _ _ 'LTR TYPEOFISURANCE AWL awvn POLICY NUMSER IMPAIDIDmPYYY srwoorivvrvi LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE. $ _ tKIAIaE rOIIBNrSD --_ CLAIMS MADE I_.__.�OCCUR ,ESEMISESIEa counsel S.. ..__.._....__._.___._._.. use ear(mitre p.ri nn ,._...,._.._.._ .....,....__.._., WA PERSONAL&ADVINJURY $ .._...................... GEM.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ _._.._. _ r'CucY[_I JECT l J we FRCS/MTS.COMPlOPADO OTHER: $ COME NEDSINGLELIMIT $ AUTOMOBILE LIADMJITw _iEtamisler _�_�,_ . _._,,.._. ... .... ....._. _ ANY AUTO DOPIiLY INJURY Vet;,roam _$ ... OWNED SCHEDULED N fA BODILY INJURY(Per occident) $ AUTOS ONLY — AUTOS PR Efrl't MItGE !TIRED AUTO ONLY _gmaccirlonLI.�...._..__ ._ AUTOS ONLY _ AUTOS $ UMMORELI ALiAO, OCCUR EACHOCCURRENCE E EXCESS LLI�AA CI AIMS.MADE 1 WA AGGREGATE s . _._...,... ___.._. ITEOE. D I I RETENTIONS (y $ - WORKERS COMPENSATION X 13 I�1F, ,�. I ERH' AND EMPLOYERS`LIABILITY ANYI"ROPRIETOR1PAiiTNERJEXECtITIVE Y L.EACH ACCIDENT •__ $....,BO 0,..... A DFPICER IEUBEEXCLUDEDT ® NIA WA 7PJUBSH0939992 i 05,1212023 05P12/2024 D.L.0I8EME-EAEiIALflY C 500,00 i pssearloiy�In NH) EP II yet derdbe under E.L.DISEASE•POLICY LIMIT $ 500,000 \.__DESCRIPTION OF OPERATIONSbelow WA DESCRIPTION OP OPERATIONS I LOCATIONS'VEHICLES(ACORD101,AdditionalRsmirk,rGhedolt,mmmbretteci.difrnrrsslips:Istinilr 4I claims for benefits iv employees in statee s other thato Massachusetts M ssachuet.employees e insured hires or to ndorsement WC 20 03 hired those employees outside of Massachusett no authorization Is s, to pay This certificate of insurance shows the policy In force on the date that this certificate was issued(unless the expiration date on the above policy precedes the Issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification . Search tool et wwvr.mass,goviiwWworkers•-corrrpensationtinvestigations1. • CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHACORDAHCE WITH TH POLICYPRO I ' VISIONb JUJ WILL BE DELIVERED IN THoAI,LEDREpRESENTATIVE . F Daniel M.Creg.*,CPCU,Vice President-Residual Market-WCRIBMA i 01988-2015 ACORD CORPORATION. All rights reserved. ACORD,25(2018103) The ACORD name end logo are registered marks of ACORD