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Home My WebLink AboutBLDTR-23-00634 rr)/ /ems 9/69// i":5 4' TOWN OF N- R�IOI'TN r , `ti0BBUILDING DEP.aRTIENT Permit Number 8Ifi „� _ . ' f�i 1146 Route 29. Mouth Varnaouth. NLS 82664 i 4$ 508-398-2231 ext. 261 Fax 508-398-0836 Date Issued 00(0 31-I Expiration Date D.� e-, a8OO TRENCH PERMIT Pursuant to G.L.c. 82A 1.1 and 520 CMR 7.00 et seq.(as amended) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant L=g , 6 „Ad,rs Phone Cell Street Address City/Town 3 _E h3 tri e P A g- 3( ? MNanmVof Excavator(if 4ifferent from applicant) Phone Cell Street Address City/Town I MA ( ZIP Name of Owner(s)of Property Phone f qt fe) Cell Street Address G I I Li'oe( . min-�. sod- aeo Ckyrrovn MA ' ZIP 713 � 7571 1�e Cr pn f ./9- �rfOp pk3a, Other 1 ° 73 6o h , � Spot, /2_L 3c. 13s Description,location and of ro 1 Permit Fee Received No( ) Yes( ) lease describe the exact location�r�of trench:6: bePlease laid in ro P p�trench and its purpose(include a description of what is(or is intended)to p posed trench(eg;pipes/cable lines etc..)Please use reverse side if additional space is needed. �et. irtECEIVED FAUG 0 3 2022 Insurance Certificatetf• � BUILDING DEPARTMENT �J ^ ^ ' L r Name and Contact information of Insurer: 1041-4 Policy Expiration Date: 3 la?, DigSafe#: OIP •1' Name of Competent Person r as defined by 520 CMR 7.02>: 1--ct r�y , !!IS 1 of 9 ' / P Ma...fivar ! Li an I /4 a `a a 9_67 3 i ; I.i*net:rade: t E"aA- 13'C61Vt BY SIGNING THLS FORM. THE APEMAN r,OWNER, AND EXCAVATOR ALL ACK.NOWLEDGE AND CERTIFY THAT THEY ARE FAMILIAR WITH.OR,BEFORE(YIMMENCF.MENT OF THE WORK,WILL BECOME FAMILIAR WITH.ALL LAWS AND RFGUI.ATH)NS APPLICABLE TO WORK PROPOSED.INCLUDING OSHA REGULATIONS. G.L. c. E2A. S26 CTMR The 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 OP CONSTRUCTION. AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY CY TO ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE CONDI-rums ATTACHED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH WORK- ME 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 THEREWTIH 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 EMPLOYS 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. APPLICANT SIG TURF it �, / DATE 6 EXCAVATOR SIGNATURE(IF DIFFERENT) _ _DATE ---------- ER'S S71GNEWDRF / " iYPltp1 '► cor t" /Ta«e ii r_M►1 N ' IEJLiIIT t!111-..�.."'".r_" �__ ow-_ rite i1�� --- `iINHtIT� .�...".`".. t>r+tr --- _ 4p .ik,1 fee 2 of A‘CORD8 CERTIFICATE OF LIABILIT Y INSURANCE DATE(MMlOD/YYYY 12/13/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THII CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIEI BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZE(: REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)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 or this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT RogersGray, Inc.-Kingston Branch NAME: 63 Smith Lane PHONE FAx Kingston MA 02364 (AM.No.Ext):508-746-3311 (Am.No):877-816-2156 ADDRESS: mail@rogersgray.com INSURER(S AFFORDING COVERAGE NAIC# INSURED INSURER A:West American Insurance Company 44393 REIDBLA-01 INSURERe:Arbella Protection Insurance Company,Inc. 41360 Reid& Laurence Ellis dba Ellis Brothers Construction 23 Enterprise Rd, P.O. Box 59 INSURER C:Associated Employers Insurance Company 11104 Yarmouthport MA 02675 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2114965942 REVISION NU THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVEBER: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 CLAIMS. INSR (ADDLISUBR LTR TYPE OF INSURANCE INSD I NIPOLICY NUMBER POLICY EFF POLICY EXP A X COMMERCIAL GENERAL LIABILITY (MM/DD/YYYY) (MM/DD/YYYYI LIMITS BKW58371201 3/1/2021 3/1/2022 CLAIMS-MADE X EACH OCCURRENCE $1,000,000 OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) S 100,000 MED EXP(Any one person) $15,000 GEM_AGGREGATE LIMIT APPLIES PER: PERSONAL&ADV INJURY $1,000,000 X POLICY j JECOT LOC GENERAL AGGREGATE $2,000,000 OTHER: PRODUCTS-COMP/OP AGG $2,000,000 B AUTOMOBILE LIABILITY 1020002607 $ 6/9/2021 6/9/2022 COMBINED SINGLE LIMIT $ ANY AUTO I (Ea accident) OWNED AoSULED BODILY INJURY(Per person) $250,000 AUTOS ONLY X HIRED X NON-OWNEDBODILY INJURY(Per accident) $500,000 AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE (Per accident) $100,000 UMBRELLA LIAR S OCCUR EXCESS LIAR !CLAIMS MADE ( EACH OCCURRENCE $ I DED I I RETENTION$ AGGREGATE $$ C WORKERS COMPENSATION f AND EMPLOYERS'LIABILITY WCC-500-5000706-2021APER S Y/N 12/3/2021 12/3/2022 STATUTE ER OFFICER/MEMBER EXCLNUDED ER/EXECUTIVE I 1 N/A (Mandatory in NH) E.L.EACH ACCIDENT $100,000 If yes, be under E.L.DISEASE-EA EMPLEMPLOYEE $100,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 i I DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(ACORD letAdditional Remarks Schedule,may be attached if more s I Certificate holder is listed as additional insured under General Liability for on-going operations when required by(wed) ritten contract or agreement. CERTIFICATE HOLDER CANCELLATION SHOULD THE EXPIRATION DATE VE DESCRIBED THEREOF, NOTICE POLICIES WILL CANCELLEDBE THEDELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth MA 02664 AD REPRESENTATIVE i''4'os'°,- ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ir 1 • • ' Commonwealth of Massachusetts - • Division of Professional Licensure • .• /-/oltalnl'eft41•19.per HE-028673 spires:12/30/2022 U LAURENCE I5ELLIS JR4r • 8 NORTH ST?:',. DENNIS POR1MA 02639 ittr. Commissioner t •Wernmea, • Hotsting Engineer Restricted•to: Excavators • Contact OPS:I:1(G6:7727:200idigenCentocartvill-7508')82a-723314u case nra ) WWw.rn ass.goviciptiopsi •