HomeMy WebLinkAboutBLDTR-23-001966 ''r) (g /d//,3/Z-
01-N-4R
TOWN OF YARMOUTH
T,4 'Pa BUILDING DEPARTMENT Permit Number 6 L 7 3
t 1146 Route 28,South Yarmouth,MA 02664
�' 508-398-2231 ext. 116E Fax 508-398-0836 Date Issued d 0 /9b'
Expiration Date PAC Q5Z
RECEIVED
TRENCH PERMIT _ ....._..__..___..- .._�.
Pursuant to G.L.c.82A 11 and 520 CMR 7.00 et se
q'fa' amended" tCT 112022
MS EMMrr MUST an FULLY COMPUTED ruon TO coNS n>ariu
Applicant Plana BUILDING DEPARTMENT
Cer — —
4ttvst Terry Walker Excavation Inc
PO Box 115 508-255-8785 508-509-5870
City/Time I MA ZIP
West Harwich 02671
Naas of Exc,aveter tit Afferent hani applicant) Phoas Gail
Strict Address
Same
City/Tame 1 MA I ZIP
Naar of t7waarce)ar Property Anne Welch Cal
street address 286 Old Main Street
City/Tows MA ZIP
South Yarmouth 02664
Other Contact [Perdu free aaroib_ f ) YesIlaaari l 1
ltiaa►ioatbn ant purism at proposal arose&
Please describe the enact location at die proposed trench and ib pawpaw t incbsds a dacripNen at*bat b tor is ceded)a be laid 1n proposed trench try piptalcaltio(saes ems.)Please we mewse yids it Wadable,'paw la needed.
Title V septic in back yard-As per plan
hymnlike Certificate it
Liab#MPP5811 L Auto#M 1 T173L Workers Comp#Wcc5005011714-2022A
Nam sat Contact latarntatlon at leasar ---- _
McShea Insurance-Christy Schneider 508-420-9011
Dig P�.MC7 ptpfatkm Ihto: 0 / 712
Ra1M Alt
20224100662
I .'tame of Competent Prima In defined by 51A t:MI 7.1121:
Terry S. Walker
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museachustisi sown Liras H E041513
l Lkenre Crad� Grade 2A
Expiratios Daze: 05/15/2023
BY SIGNING THIS FORM.THE APPdCAAiT, OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND
atarrwy
THAT THEY ARE FAMILIAR WITH,OR,SORE COMMENCEMENT OF THE WOW WILL BECOME FAMILIAR
writ AU.LAWS AND REGULATIONS APPLICAILE TO WORK PROPOSED,INCW1ING OSHA REGULA'I ON&
GL a STA, EIi CMI 7.114I d sec, AND ANY APPUCA,LE MUNICIPAL ORDIN REGLQATIOIWW AND THEY COvitmAWT AND ACM THAT AU.WORE DONR HRL'R� •Y-LAWS AND
SVCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND W TA��THE LSSIISSUED®MOW. THE CUNDmI7i0ONS l+t8 SET FORTOR
TH
THE UNDERSIGNED OWNER AVTHORIZSB THE APPLICANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER. AND
ALIO. FOR ME
DURATION OW CONSTRUCTION, Ammar= PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
CONDITIONS ATTACHED AN�RWA AND REGUATIONS minaWORK UCHWOCONFORMITY win THE
COVERING SUCH A^ORIt,
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COWLS AND INCURRED BY THE
MUNK]PALT Y iN CONNECTION WITS THIS PERMTTAND THE WORK CONDO THEREUNDER,
INCLUDING BUT NOT LIMITED TO Zhu THE REQUIREMENTS Of STATE LAW AND common OF
THU PERMIT.INSPECI70N8 MADE TO ASSURE COl1 PLLANCE TIEREWL TI,AND MEASURES TAKEN SY THE
MUNICIAt1TT TO mama THE PUBLIC WEE THE APh.ICANT OWNS Ot RXCAVATOp HAS FAILED TO
COMPLY nuatiwrry INCLUDING POLICE DETAILS AND OTHER RZMFDLAL MEASURES DEEM=
NECESSARY EY THE MUNICIPALITY.
THE UNDERSIGNED APPLICANT.OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEIE?ID.
INDEMNITY, AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS SES LTINS AND
ANY AND ALL LIAIIIII'LY,CAUSES OR ACTION.COSTS,AND EMPLOYEES FROM
FROM OR AIRISTNG
or ANY INJURY DEATLI, LOSS. OR DAMAGE TO ANY PERSON OR PROil:ETy DURING THE Wont
CONDUCTED UNDER THE MUM.
APPLIC TTT SIGNATURE
DATE 10/11/2022
EXCAVATOR SIGNATURE ILF DIFFERENT)
DATE
OWNER'S SIGNATURE IF DIFFERENT}
DATE:
10/11/2022
11. *
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