HomeMy WebLinkAboutBLDTR-23-003494 in t lei i// 741--- —
• .o� :Y R TOWN OF YARMOUTH
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_\ BUILDING DEPARTMENT Permit Number —
1146 Route 28,South Yarmouth,NIA 02664
`�' e,, 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued Z3
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Expiration Date
$50.00
TRENCH PERMIT
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant Phone Cell
Street Address 7714—3,-3 ly'( C)
Email Address:
Cityriown MA ZIP 1 (c,t+ ►'1�t +7r?4 ,c 0.1
5 ovi< 1o.✓imCAJ C O J O U Li
Name of Excavator(if different from applicant) Phone Cell
Street Address 5 _
Email Address:
Cits,Town I MA ZIP
Name of Owneris►of Property Phone Cell
Street Addr.s Stein-ev i
) ln+'ciod,b,lr{ Email Address:
City/Town �1 ;AMA ZIP
7
Other Contact I 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.
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Insurance Certificate#: 'V c 1NJ 1 c D72- 4
Name and Contact Information of Insurer:
bivevL SS44— 47 -6
Policy Expiration Date:
Dig Safe f: I
if)4)- 5.-Zvi-c—1 7
IName of Competent Person las defined by 520 CMR 7.02):
(30111 ( (Atli v
i
' Name of Competent Person(as defined by 520 CMR 7.02):
JJhy C‘i\c,1"
Massachusetts Hoisting License# -ti_ 11(j 7,4) I
License Grade: ) 4-
Expiration Date: `/ (,) /1, 3
BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND SERTIFY
THAT THEY ARE FAMILIAR WITH, OR,BEFORE COMMENCEMENT OF THE WORK,WILL BECOME F• ILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGUL: TIONS,
G.L. c. 82A, 520 CMR 7.00 et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LA S AND
REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISS ED 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 A ' t THE
EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO, F I R THE
DURATION OF CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPAL TY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY H THE
CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS GOVERING 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 CONDITIO S OF
THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES TAKEN B THE
MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS F• u ED 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 1 EFEND,
INDEMNIFY, AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEE. FROM
ANY AND ALL LIABILITY, CAUSES OR ACTION, COSTS, AND EXPENSES RESULTING FROM OR ARISL G OUT
OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNATURE
(c)"4•X 1j21/C/L. DATE - 1(z)7A
EXC1VATOR SIGNATURE(IF DIFFERENT)
�-� DATE '7 1-)--
OWNER'S SIGNATURE (IF DIFFERENT)
DATE: 4
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