HomeMy WebLinkAboutBLDTR-23-001873 Pi et 1 i
0T.YgR-s TOWN OF YARMOUTH
DEPARTMENTi )/ Yi2
° BUILDING Permit Number
O -e F 1146 Route 28,South Yarmouth,MA 02664
('!�5�MATTACh «E �' 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
Expiration Date C
Pursuant to G.L. c. 82A TRENCH PERMIT �. • - ��----
and 520 CMR 7.00 et seq.(as amend d OCT 6 2022�
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSI!DERATi01V BUILDING DEPARTA0 NT
Name of Applicant
Street Address o rr� "" �� One�O� Cell
ca. 3Gp 'SGPd
...► S `"`"a`- ,vr4 Email Address:
City/Tow�n MA ZIP S7i �✓ n s Q % L, Cain
A- , ( _ nor- 02Sro /
Name o xcavator(if different from applicant)
CA2„�e SPhOOe Cell
Street Address
2 G i �o/arri do/%w ed (ic) � .Z4'Y- 7y9�
City/TownEmail Address:
MA ZIP
Name of Owneris►of Property p
0.NNt 04C.coM/.l Phone Cell Street Address
7� �«� s c 6y3 ) 32d — (3 7
City/town Email Address:
MA ZIP
L.), /AA.rnovAL. Aw Other Contact d Z(o G y
Permit Fee Received No ) Yes
Description,location and
purpose of proposed trench:
Please describe the exact location of the proposed trench and its include a description
p i nofwhatis(orisinteaded)to
be laid in proposed trench leg;pipes/cabk lines etc..)Please use reverse (de if additional space is needed.
i pfjrLL ".'- Z Li.sk .-
' Insurance Certificate*:
Name and Contact Information of Insurer:
Polk Et iiration Date:
Dig Safe)!:
Zoz-z_3goaGn — -
1 Name of Competent Person l as defined by 520 C MR 7.02):
_c-1
Name of Competent Person(as defined by 520 CMR 7.02):
-
Massachusetts Hoisting License# ,y`C_ /4eg8
License Grade: — fao f5��,,
i✓at/L Ex e iration Date: g elS 2 o z
BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL
THAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF THE WORK,
BECOME AND CERTIFY
KITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCL
G.L. c. 82A, 520 CMR 7.00 et seq., �� WILL FAMILIAR
REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE U UDING OSHA REGULATIONS,
9� AND ANY APPLICABLE NIUIVICIPAL QRpINANCES, BY-LAWS AND
BELHOW.
WORK ,L COMPLY THEREWITH IN ALL RESPECTS AND WITH THEUNDER THE PERMIT ISSUED FOR
BELOW. CONDITIONS SET FORTH
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR
EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER,R PERMIT AND THE
DURATION OF CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTED B
ENTER UPON THE PROPERTY TO MONITOR AND AND ALSO, FOR THE
CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS GOVERIN Y SUCH THE MUNICIPALITY TO
INSPECT THE WORK FOR CONFORMITY WITH THE
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY A G EVR ALLWOY T
REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED
MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED�SEVERALLY TO
INLUDING BUT NOT IMITED TO ENFORCING THE RE BY THE
THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND THEREUNDER,
QNC E STATE LAW AND CONDITIONS OF
MUNICIPALITY TO PROTECT THE PUBLIC WHERE
COMPLY THEREWITH INECTDING POLICE DETAILST AND OTHER APPLICANT OWNER MEASURES TAKEN BL THE
NECESSARY BY THE MREML MEASURES E MED FAILED TO
MUNICIPALITY.
THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE
INDEMNIFY, AND HOLD HARMLESS THE M JOINTLY AND SEVERALLY TO DEFEND
ANY AND ALL LIABILITY, CAUSES OR ACTION, COSTS, AND EXPENSES RESU
LTING FROM OR
�CII'ALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM
OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY ARISING OUT
PERSON OR PROPERTY DURING THE
CONDUCTED UNDER THIS PERMIT, WORK
T SIGNATURE
DATE ✓0 ,3 ZZ
E CAVATOR S NATURE (IF DIFFERENT)
DATE 0D t Z
OW ' SIGNATU DIFFERENT)
DATE: P- 5 2e
RDVEIiy far
Po metixo� ' rrt €too _
Ih se
-ftR I G A TH ,
-- _=ate _ �----APF�tio�Fee