HomeMy WebLinkAboutBLDTR-23-003414 .Y- TOWN OF YARMOUTH //aibl ,'z'2.d/le
fO gR4o BUILDING DEPARTMENT Permit Number giii) e- Z3-
` 4 ),5i 1146 Route 28, South Yarmouth, MA 02664
,.�,r„ x,, 508-398-2231 ext. 1261 Fax 5(18-398-0836 Date Issued D Li )t-'�
Expiation Date e r (19
'a, °i $50.00
TRENCH PERMIT "; E D
Pursuant to G.L. c. 82A I1 and 520 CMR 7.00 et seq.(as amended)
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rms PERMIT MUST BE FULLY JtA TID
COMPLETED PRIOR TO CONSIDP EC 2 0 2022
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Haase of ApplicenfA7 0511 Phone Cell rs d I L B I n,I , R-i'w T
By Street Address ' t 17 e W 12Dyko 5 - 5 C)
City/Town MA ZIP
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Name of Excavator(if different from applicant) Phone Cell
Street Address
City) own MA I ZIP
Now of Onrls Pi at s , i g Phone Cell
Street Addr j�
Ckyaorn MA I ZIP
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Other Contact I Permit Fee Received No( 1 Yes( )
Description,locates and purpose of proposed trench:
Please describe the exact beatioa of the proposed trench sad its purpose(include a descriptea of what is(or is intended)to
be laid in proposed trench(ea;pipes/cable limes etc..)Please use reverse ride if additional space is needed.
vEpti G 1114% P-042 D
Insurance Certificate M: 1 I ,. /t 15 9 c
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Name and Contact information of Insurer. — —
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Pod icY Es ration Date. ---- - -
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1 Name of Cnm tent Person i as►efined by 52.11(. IR7 :
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Massachusetts Hoisting License N f `'
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• License Grades � Y�- 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 c. STA, 5211 CMR 7.04) 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.
• CANT SI6NATTURE 1
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EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
SIGNATURE I IF DIFFERENT) `';�
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