HomeMy WebLinkAboutBLDTR-23-000480 r:n Y IUWIN Utz' YAKIVIUU'1'H /ria. Ied WaN/.2g
, tr/ \o• BUILDING DEPARTMENT Permit Number /�
OI 1146 Route 28, South Yarmouth, NIA 02664 _
' MATTA r „•._�2', 508-398-223.1 ext. 1261 Fax 508-398-0836 Date Issued O d d
_,._....__ Expiration Date a1 .19`71L/JUL 29 2022 $50.00
BUILDING DEPARTMENT TRENCH PERMIT
ay:
•
Pursuant to C.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
rills PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant Phone
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St reet Adder. Jb , j`� ; G i
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City/Town n MA l ZIP
Name of E ator(if different from applicant) Phone
Cell
street AckiA oho L11,irie.
City/Town 1 MA I ZIP
Name of Owners►of Property Phone
r �' Cell
Street Address
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City/To MA ZIP
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Other Contact I Permit Fee Received No( ) Yes( I
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 (es; pipes/cable lines etc..)Please use reverse side If additional space la needed.
C_.3"-01(---' .
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Insurance Certificate M;
Name and Contact Information of Irxsurer:
. QCY:j\C'cc L (AAA 1'�. 4lY(,%l.r J1 ' /
Policy Expiration Date: /O/h 2t;L) 1 J /� 1�.1 Ltd l � �� ��
Dig Safe A:
a-91 — S1oo
Vane of Competent Person (as defined by 52.0( tR 7.02):
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Hoisting Lkense I P-(� 1 5 .�
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Licence Grade; lS 1' COG 1 n � '3 149 I *�
Ex.'rmtion Dale;
BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH,OR, BEFORE COMMENCEMENT OF THE WO
BECOME
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED.INCLUDING WILL
REGULATIONSR
G.L a VA, 520 CMR 7.00 et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES,
REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT IT ISSUED S FOR
SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH PERMITSETFFORTH
BELOW THE CONDITIONS SET FORTH
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE O
DURATION OF CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTEDWYET M NICO, FOR THE
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT BY THE MUNICIPALITY HTO
E
CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH WORK
R CONFORMITY WIIA THE
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 R
THIS PERMIT,INSPECTIONS MADE TO ASSURE CO ENTS OF STATE LAW AND CONDITION OF
MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT O ' OR EXAND MEASURES TAKEN THE
COMPLY THERZWTTH INCLUDING POLICE DETAILS AND OTHER REMEDIAL EASCURES AVATOR DEEMHAS
ED FAILED TO
MEASURES
NECESSARY BY THE MUNICIPALITY.
THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDEMNIFY, AND HOLD I ARMLF.S 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
CONDUCTED UNDER THIS PERMIT. PROPERTY DURING THE WORK
APPLICANT SIGNATURE
DATE � �`�
EXCAVATOR SIGNATURE(IF DIFFERENT)
/'• DATE ZZ Z7,
OW ER'S SIGNATURE (IF DIFFERENT)
DATE: ' -
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