HomeMy WebLinkAboutBLDTR-23-002345 '',AR ��TOWN OF A MOU UTH !em (E- 7, —(.534."'
"- o BUILDING t)EPARTNIENT Permit Number
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;`' . 1146 Route 28, South Yarmouth, MA 02664
5t)8-398-2231 ext. 261 Fax :+t)8-398-0836 Date Issued
Expiration Date
TRENCH PERMIT
Pursuant to O.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMITPE MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION j Name of Applicant AT 8 �• ic_ Phonege,. -%4 777Cell �Z
-07/07'ge
Street Address 3 (,W jjoks. pavA.
City/Town MA ZIP
clAiii holottiA ink, cetpAq
Name of Excavator(if different from applicant) Phone Cell
Street Address
City/Town MA ZIP
Name of Owner(s)of PropertyL Co 1\SS Phone Cell
Street Address�, qg kale_ 2$
City/Town MA I ZIP
Wei Yalmot. M j 007673
Other Contact 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(eg;pipes/cable lines etc..)Please use reverse side if additional space is needed.
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1 OCT 31 2022 a
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Insurance Certificate#: c p il. ,,d if o
30.
Name and Contact Information of Insurer:
i AA/ iti ad11'lQ._
Policy Expiration Date: /
f Dig Safe#: ——
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Name of Competent Person(as defined by 520 CMR 7.02):
.—_____Piall Aliee417
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Massachusetts Hoisting License fi hie"/ 3/y
Lieeuse Gracie: ge-Rii, • Expiration Dote: , /
BY SIGNING THIS FORM. THE APPLICANT,OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF THE WORK,WII3",BECOME FAMILIAR
mirror ALE.LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,
G,L. e. $2A, 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 ANI) WITH THE CONDITIONS SET FORTH
BELOW.
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR TREYS PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO, FOR TIM
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 SUO'II 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 WITIX 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 ANI)EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEPEND,
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 WARY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APPLIC • S N ;
DATE /0-3/-,41•7
E AVATOR.SIGNATURE(IF DIFFERENT)
DATE _.. _
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OWNI R'S SIGN . RE(IF DIFFERENT)
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