HomeMy WebLinkAboutBLDTR-23-001806 ' 13LI�12 23-W( OL
• �o� ��� TOWN OF 1 ARMOI1- -I
' BUILDING DEPARTMENT Permit Number
lot - '_ 7).31 1146 Route 28, South Yarmouth, MA 02663
'`nATTA<n sue- 508-398-2231 ext. 261 Fax 508-398-O836 Date Issued
Expiratio . C E 9
L OCT 5 2022
TRENCH PERMIT BUILDING DEPARTMENT
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Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as a
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant/ .. 15 ow( Co, YA�i Phone�a f_ Cell �Ja..3� 7
Street Address wit
`i es peak
City/Town MA ZIP
cu4 Yctrmx mAr, C0664/
Name of Excavator(if different from applicant) Phone Cell
Street Address
City/Town MA ZIP
Name of Owner(s)of Property 1a girt/intern- Phone Cell_(/5703
Street Address 36 /,,C,�,or
City/Town MA i ZIP C�
Xcivo —
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.
Z i51cf! 4e4v lSap 6721104 eefl C 7 4K, N ) D.6ol ile&t/‘2J 5ZO 6a/ram
tea Gat? atant 5 /plat - / pj 7aid
Insurance Certificate lt: CPA / /Ala,_ 30
Name and Contact Information of Insurer:
/46 T—it,lr•✓na�lata ✓ 6M/a44 Ca 4e. Laci/fcace Policy Expiration Date: / /.a2
! Dig Safe#: aoA702y0a25 369
Name of Competent Person(as defined by 520 CMR 7.02):
ya l (u ee4ey
1 of 2
Massachusetts Hoisting License II /kr..CO eqg
License Grade. E' RA Expiration Date: /fr v^g,2
BY SIGNING THIS FORM,THE APPLICANT,OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERIIF Y
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. c, 82A, 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 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.
APPLIC $ GNA RE
DATE IO'`�r 4:V.2
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
0., `E'R'Ar
.VIRE : D FERENT}
DATE: 1 D / ....5 z .r)/
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• F0 ati(}tl --Dm&I write'ht IhIN't ctiiroA .
PERMIT APPROVEIL G'HY.. ._ .' ',., ,v.:r pplicittiati FY
P1~otrrfll C AUT ORLIb . . _ • • . .
CONDITIONS OFAIIRIVcf :' • • . .
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