HomeMy WebLinkAboutBLDTR-23-003492 le /02-/oz-7/;--
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10 BUILDING DEPARTNIENT Permit Number 131 1)---4
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diott44 c 1146 Route 28,South Yarmouth. MA 02664
4
Date Issued 6 0 3 1-M2.-
508-398-2231 ext. 1261 Fax 508-398-083o Expiration Date
$50.00
T CH PERNI1T
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(aa amended)
nus PERMIT MUST BE EVIL Y COM' D PRIOR TO CONSIDERATION
Nom APPlicend a 6 ii.coAcki 1Art. Phone
Street Acktress 56E- 41-1-ob5,3
.r -3(ut Ram ttA
City/Town MA ZIP
02.5(.1
Neese of'Excavator a different Irons iipp/Icanl) '
Street Address
. -
City/Town MA ZIP
Nam*of Chwfierisi of Prepesty jpaot oxcr -j-oh, 60.10,0s Phone Cell
Street Address
to 0041 t'Aci,4.1e.J Qui\ Q.00,6,
CkylTewn MA I ZIP
1(k(f110044
Other Cattail I Pernik Fee Received No( Yes
baserlptios,locatiois and purpose of proposed trench:
Pleases describe the exact loestion ciths proposed,trench sad RS purpose inc • a&scripting or it h tor is in )
be hod lo proposed trends(eg;pipes/rah*Hata etc.)Please use reverse • if stiditionni space Is • to
51-0,1\Ckki Oi 11S4°-'
RFC, E1VED '
II DEC 2 2 2022
Insure/lc,t'enincs"if 52'59 81-34 BUILDING DEPARTMENT
Name sad Cowart Informailon of Insurer,
Seteck4, tY1S.
Po Et don Dote:
102.2M0 1507
Nors---;;;‘1 coospetent Pens'sae defined by SIB t NUR 7 02):
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SY SIGNING THIS Y'ORM. THE APPLICANT. OWNER, AND EXCAVATOR ALL ACLNOWLEDGZ AND CERTIFY
THAT I HEY ARE FAMILIA,Wfl H„OR,SIEFORE COMMEN OF THE W BECOME FAMILIAR
ALLYvTTIL LAWS
S G APPLICABLEWORK ' °'r • D, UDING OSHA,REGUTATIC NS.
[.ve. CM 7.* rt AND ANY CABLE - AL ORDINANCES, BY-LAWS AND
REGULATIONS "Y COVENANT AND AG THAT ALL WO NINE UNDER TIM PERMIT ISSUED FOR
SUCH WORK CO Y THERE 3,;.CTS AND W CONDITIONS SET TO
BELOW.
THE UNDERSIGNED OWNER AUTHORI APPLICANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WORK N Tag PEO OF Tin OWNER, D ALSO, FOR THE
DURATION OF cotentvenom AUTO MESONS MILE APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR WORE FOR CONFORMITY WITH THE
CONDITIONS ATTACHED TO AND ma LAWS AND DEGULATNINS COVE SUCH WO
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AG JOINTLY AND SEVERALLY TO
REIMBURSE THE MUNICIPALITY WEE ANY AND ALL COSTS AND MENSES LECUIRED'BY THE
MUNICIPALITY IN COt NECTIO$WITH THIS PERMIT AND THE WORK CONDUCTEDTHEREUNDER.
INC."LUDII SIFT NOT LOWED TO ENFORCING rat REQUIREMENTS OF STATE LAW AND CONDITIONS Of
THIS natmit INSPECTIONS MADE TO ASSURE C*- THEREWITH,AND MEASURES TAKEN BY THE
MUNICIPALITY PROTECT THE PUBLIC WHERE " £ APPLICANT 0 ° OR nativATOR HAS FAILED TO
COMPLY THEREWITH INCLUDINGER *e L MEASURES DEEMED
a.: .RY BY MUNICIPALITY.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDEMNIFY, AND HOLD HARMLESS A ALL OF ITS AGENTS AND EMPLOYEES FROM
ANY AND ALL LIABILITY,CAUSES ActioN,CIO CIWIS,AND A* ES .: A,' LUNG PROM OR ARISING OUT
OF ANY INJURY, DEATH, LOSE, OR DAMAGE TO ANY PERSON OR O D G THE WORK
CONIXICTED UNDER THIS PERMIT.
APPLI SIGN RE
DATEIZ�/LIL2
EXC TATOR IGNATURE ilF U RENT,
DA TE
i WN :WS SIGNATURE IF DIFFE
._.. _. w DATE:
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