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HomeMy WebLinkAboutBLDTR-23-000996 pltizz//SZ Pf*YN_, !SOWN OF YARMOUTH o BUILDING DEPARTMENT Permit Number of • y 1146 Route 28,South Yarmouth, iMA 4)266d ? 3`1 �. NATTA ' c-: 508 398 2231 ext. 1261 Fax 508-398 0fi36 Date Issued ��(� •-av3.5 Ya"y Expiration Date $50.00 TRENCH PERMIT RECEIVED Pursuant to G.L. c. 82A fI and 520 CAM 7.00 et seq.(as amended) rHIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION AUG 2 4 2022 Name of Applicant , Cry ,rl� Ui�cA,c)y or�Sk-roc + ? G /� C Cell BUILDW .• - r NT Street Address LI 5 Lfyjt , i , g 5 08- `1, O - 9m By: — — City/Town �"� ZIP tf\t/A)) 3, i MI v .,(igt Nano of Excavator(if di#Yerent from applicant) Phone Cell Street Address City/Town ZIP iill Neale of Ow lens)of Property Street Address l4 AY�� Phone Cell City/Town MA ZIP --`-- 14 >n / 013 Sy Other ContsuY Des.cription,locatioa and Permit Fee Received No ► Yes Please describe the exact location of the ! trench: be laid in proposed trench( proposed trench soar!its purpose(include a dl�r;�;y n�''what b(or�iy�intet )to es;pipes/cable lines etc..)Please use reverse side if additional s 1 CL)� pace is needed. Is� -ee f e rl-t;-rn i r��inc�.J l' `�s��L�u�C Svv te<..Pd�ie�o (fie) ' ^I 4 C, 2i,, , ) a.i xal+ S i22� tcm.edo 9 1e e y„„jr ' ' + „ `� ,r aa 54t Q k/Le (ce e� • 4ll Vl��S � 1 IQ-Pt Insurance c'ertifkate it: Nave and Contact Info don of insurer: k,.. 4,1 PU- fox .3 5 OlUa.1-onn� ti� Pnlity Expiration later ►V JCS Ube 0Dis Safe p: 1_-____ � � 3,0 5lpla% Varaaa of Competent Persoa ias defined by 520 t 1IR{t7 >{t7 >I; Iof2 Massachusetts Hoisting License N / 3 gSa • License Grade: c2. A 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. IZA, 5211 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 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 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. APPLICANT SIG DATE EX AVATOR SIGNATURE(IF DIFFERENT) DATE ER' SIG RE( DIFFERENT) ATE: //,)- Fret CUj/Tea eaa-tlrr omt b iMinodal -- MAW Attila= Arprialdte rot 2 ©f2