HomeMy WebLinkAboutBLDTR-23-001962 ni
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BUILDING DEPARTMENT Permit Numbea-
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_ y 1146 Route 28, South Yarmouth, ivlA 02664
� 508-398-22 31 ext. 1261 Fax 508-398-0836 Date Issued UJj
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Expiration Date ((„L�4- On 5 Zd 6,
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TRENCH PERMIT
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as antendeai3
CT 112022
Tins PERMIT U HE FULLY COMPLETED PRIOR TO CONSIDERATIONi-;; NO DEPARTMENT
ARTMENT
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Natty of.�pplicarat Phone Cell
Street Address ,( 1
3 3 lay*a L) ( 50/-4`L1-? l7
City/Town
/J yy�1�t AMA ZIP
ttirti
Naar of Excavator(if different from applicant) Phone
Cell
Street Address e+
City/Town I MA I ZIP
Name of Owner-fit)of Property Phone
Cell
Street Address
Clityflorn, MA I ZIP
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 s description of what is(or is intended)to
be laid in proposed trench(err pipes/cable lines etc..)Please use reverse side if additional space is needed.
$0)t-c c_ sue,
Insurance Certificate Pk ,p11.13
p (30 ...3 Name sod Contact Information of Insurer:140
�'-L"C-024)Ar(01-44( t1) .. i E ld? a s—
Policy Fspiration Date (2_— Z,ei 2.. �
Dig Safe Ph 2,6 2_2_,3 70 .6
Name of Competent Person(as defined by 510(MR 7.(U):
I of 2
Massachusetts Hoisting License# ti El - / S(j 6f
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License Grade: (-4—. -3L 4 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 WORE, WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,
G.L. e. 32A, 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 TUB
MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OP 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.
APPLICAN "SI NATURE,, _
,; ""11 DATE to ---7 '2c'22.-
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EXCAVA ( 'SIGNATURE(I DIFFERENT)
/% ��v � DATE IC> 7 —L
OWNER'S SIGNATURE(IF DIFFERENT)
----- DATE:
Far C>I�(Ts'wn an- I]r not w rite i!tke imam.
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A true
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AO;00%-"' I kidairittiili 1)atie _______ Wittittrji
$50.00 ---,-- -
TRENCH PE RNIIT
Varettarit ite G,1..,4..%$2A II *1141 520 c7OR 7.00 et Setttatt stalendted)
f 1415 pirttstee attrr tit nit t I"cratetarett"'Nitta to retaStItteltATION
1 140.C.--,11.2
I area Adders --,
t. Ste 3S.e2...tittitZc 1:44'11 _ _ 50-2.4'/I
zit
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tNee;tor CiNifi toter a ttireetat Item tijaitreatt - Pleats
$ i
fi iteteer Atieleeet .... I
c.5t414,4 1
,cityle.r.# rirt:zria. 't
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. slim.or°areal.)a:Property Placer CAI
f-7,...-is
i Street Atareatt
3 h .__LC ice_.(...c!..*2-1-, 223) _ , _
1 Chtylittret. MAL 0"I pi,. yr,41,,z14,d,cyta tit 1 to zr„-r3
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Ceattatit Perak FRO ROttitO1 NO LYE'( i ...---1,
INOrrirden,fOritiOaratrid purpose ot petelastati tratetti
Mese*describe the exact Remotion of iist propeard trench..d its parrot*(include*iltsetipilas eit sihst it 0704.11 iritenek•ID tiii.
be isiti in iciirvsprood trench Olt.Fripesiesbie rim*tic)'Prairie it*t re'lesa atte It sdditioisai mpaire is weeded. i
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kuarance terfickste t: CpA43C) 1(....i. ..,,.'ii.-3c
...i eirtti sit/frtfrliiitturli:n a insmetr
toory Expirslkwt n,..iite t 2--7„1—2.4,2.3.,
Dig Sofr ifr r-i. , ,..i
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1 Nelms of ipettrat lorrs00 IA"donned P 520 4..%II 7 el): 1
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sir SIGNING hilt FORM. THE AE"PIJC'ANr.OiwNEH.AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH.OR,RE PORE COMF(RNCEM 'Of THE WO WILL
BECOME Wrrii.ALL LAWS AND IE( 1LA TIONS APT!_ICARLE TO WtlRK ritOroSED.1N[.LZ D(NG OSHA.REA;t1I ATI(}NS,
L a tG1. sle CMR T.OI rot wel AND ANY A,VUCARI,tt MUNICIPAL ORI5DIANCE*. LAws Ar(D
RECLt/,TONS AND THEY COVENANT AND AUREE THAT ALL WORE DONEUNDER
THE PG•>�M
SUCH WORK WILL COMPLY TIIFREWrTIH IN 411. RESTECTS AND wrTH TIIE (CONDITIONS SET FORTH
BR OW.
rlit Lfi DFSL.StGP OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THt PERMIT AND TIM
F_1CAVA:TOR 1O UND&RTA:F.E SUCH WORK ON THE PROPERTY OF THE OWNER. AND ALSO. FOR THE
DILATION (W LiorarTittitTIIlN. AUTHORIZES PERSONS DULY APIN/LNIrED SY THE MUPirCIPam TO
CONDrTlt ATT 1"HED*EIFFY 1,NDTTIM LAW" REG JL E NS COVE r;IUCHWORIL
TflE CUNVILILSIONFD APPLICANT.OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REIMBURSE THE MILRNICWALI Y FOR ANY AND ALL COSTS AND EXPENSES PICCHU=SY THE
iL,!TCLP.AL(TY IN CONNECTION WITH THIS PERMIT AND THE WORE I I TIM R. 4Y
IN(-LIrDING Our NOT Lou-maToE ENFORCING THE 9EQVERU1 STATETAI<IIN ay OF
1?UN PERMIT.B NB MADE TO A.SSI.IIIE COMPLIANCE T WrTlt AND Ml
THE
MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO
COM?LY TlIEil*W ITH I?4C1L'DING POLICE DETAILS AND OTHER REMEDIAL MEASIJEYS DEEMED
NECESSARY SY TILE M1EL IC'LPAL.TI'Y.
THE UNDERSIGNED AP?UCANr.OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
AND HOLD HARMLESS THE MUNICIPALITY Ant ALL(IF ITS AGENTS AND E.AirwyELS PROM
ANY AND ALL LIAELLITY,CAUSES OH ACTON,COSTS.AND EXPENSES RESULTING FROM OR ARISING OLT
of ANY INJURY. DEATH, IA-Is rA-Iss. OR DAMAGE TO ANY PERSON OR FttOPEII'1Y IlURL'tG THE
WORK
CONDUCTED UNDER THIS PE MIT.
APPLIC SI NA IRE;
f DATE Eel - -2L12
E CA VA R+,SLGNA RE j DIFFERENT)
owp(ER'S57i.MA' REfIFDIFFERENT,
DA TE:
Affikamiya re*,
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