HomeMy WebLinkAboutBLDTR-23-001956 /cal /d//3/?
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TOWN OF YAR�'�IOUTII
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o'� gR� BUILDING DEPARTMENT Permit Number 6o TIZ -r � 1146 Route 28,SouthYarmouth, NIA 02664
508-398-2231 ext. 1261 Fax 508-398-08 36 Date Issued 6/ q 5(
Expiration Date (,//1*, 3 N
$50.00
TRENCH PER,N1IT RECEIVED__ __ ,-._..._.._.....�
Pursuant to G.L. c. 82A §1 and 520 CMR 7,00 et seq.(as der )'OCT 12 2022
rNIS PERMIT N1UST BE FULLY COMPLETED PRIOR TO CONSfDP.RATTON
Name of Applicant
C.C.Construction,Inc.
Phone Cell ��=N T
Street Addreta 11 Cantor Court 508-398-1811
City/Town MA I ZIP
Plymouth MA 02360
Name of Excavator Of different from applicant Phone Cell
Street Address
Cityffown MA ZIP
Name of Ownaris)of Property Phone Cell
Greg Bilezikiar
Street Address
231 Willow Street
Cly/Town MA ! ZIP
Yarmouth Port A 02673
Other Contact I Permit Fee Received No( ) Yes( )
Deseripdon,location and purpose of proposed trench:
Please describe the exact location of the proposed trench sod its purpose(Include a description of what is(or is intended)to
be laid in proposed trench leg;pipes/cable lines etc..)Please use reverse ride if additional space is needed.
Drainage utility installation at the southwest side of the property in relation to the
construction of a new parking lot for which C.C.Construction has been subcontracted
by Dellbrook/JKS to perform the site work.
{ Insurance Certificate I:
CPA 548193111
Nate and Contact information of Insurer- HUB International New England
Catherine Lawrence
508-235-2207
Policy Expiration Date: 7/1/2023
Dig 20223907544
Name of Competent Peruse tas defined by 520 CMIR 7.01):
Todd Theroux-Foreman
I of 2
%fna mchusetts Hoisting License N
•
License Grade: Expiration 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
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS.
G.L e. a2A, 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 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.
., T SIGNATURE
DATE — t t EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGNATURE I IF DIFFERENT)
DATE:
Foe l eve see— [iws mot write le Mit
pi iret os Trot
DOI
COPE=Ali
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