HomeMy WebLinkAboutCopy of License - BLDT-23-2107 20709Massachusetts lloistius License # ltf //6( L1
License Grade:kl [- vi ?-, r- t,rExpiration Date:
Name of Competent Person (as defrned by 520 CMR 7.02):
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BY SIGNIIIG THIS FORM, THE APPLICANT, OWNER, ,{NID EXCAVATOR ALL ACKNOWLEDGE AN'D CERTIFY
THAT TIMY ARE FA}IILAR WITII, OR, BEFORE CO\I\IENCEMENT OF TTM WORK, WILL BECO\,IE F,d\IIL[{R
WITH, ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED, I\CL{.,'DING OSHA REGULATIONS,G.L. c. 82A, s20 CMR 7.00 et seq., ANID A.l\Y APPLICABLE I{UNCIPAL ORDIII.{NCES, BY-LAIVS AND
REGI.]'LATIONS .A.ND THEY CO\TENANT ANID AGRTE TIIAT ALL WORK DONE UN.DER THE PERITIT ISSUED FOR
SUCH WORK WfLL COMPLY TTIERE1VITH LN ALL RESPECTS ANID WITH THE CON'DITIONS SET FORTH
BELOW.
THE LTNDERSIGNED OIVNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PER.I\{IT AND TIIE
EXCAVATOR TO UNDERTAKE SUCH 1VORK ON THE PROPERTY OF TIIE OWNER, A-N'D ALSO, FOR THE
DIJ'RATION OF CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTED BY THE T,IUNICIPAIITY TO
ENTER T'PON TITE PROPERTY TO IVIOMTOR AN-D INSPECT THE WORK FOR CONFOR}IITY IITTH THE
CONDITIONS ATTACIIED IIERETO AND TIIE LAWS AND REGULATIONS GOIERI\G SUCH \,VORK.
THE I,NDERSIG\-ED APPLICANT, OWNER AN'D EXCAVATOR AGR,EE JOINTLY AND SEITRALLY TO
REL\IBURSE THE NIUNICIPALITY FOR ATi}"AND ALL COSTS AND EXPENSES INCL]RRED BY THE}IU\ICIPALITY N CONNECTION IVITH THIS PER}IIT A\D T}IE WORK CONDUCTED TIIEREUN-DER,
I}iCLUDING BUT NOT LL\ITTED TO EIiFORCING TIIE RXQUIRE}IENT'S OF ST-{TE LAW A\D CO}'DITIO\S OF
THIS PER\IIT, L\SPECTIONS }I.{DE TO ASSfRE CO}IPLLI\CE THEREI!'ITH, A\-D }IEASURES TAKEN BY TIIE
NIINICIPALITY TO PROTECT THE PUBLIC IVIIERE THE APPLICANT O\.r'ER OR EXCAV.{TOR H.\S F.{ILED TO
CO}IPLY THERE1VITH I\CLLDING POLICE DET.{ILS A\D OTHER RE\IEDL{,L \IEASI R-ES DEE}IED
NECESS.{RY BY THE NILNICIPALITY.
THE UNDERSIGNED APPLICANT, OIVNER AND EXCAVATOR AGREE JOI\TLY A)'D SEVER{LLY TO DEFEND,
I\TDEMNIFY, AND TIOLD HARNTLESS THE NIUMCIPALITY AND ALL OF ITS AGENTS .AJ\D E}IPLOYEES [RO}I
ANY AND ALL LIABILITY, CAUSES OR ACTIO\, COSTS, AND EXPENSES RESULTINIG FRONI OR.{RISING OUTOF ANY INJURY, DEATH. LOSS, OR DANIAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CON'DLTCTED UNDER THIS PERI,IIT.
APPLIC.{NT SIGNATURE
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EXCAVATOR SIGNATLIRE (IF DTFFERENTJ
OIVN'ER'S SIGNATURE (IF' DIFFERENT)
DATE:
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DATE