HomeMy WebLinkAboutBLDTR-23-000651 GG j i-e sL8'/tJ
�� TOWN OF YARMOUTH
r1 .Ov+Y`9R
a BUILDING DEPARTMENT Permit Number023
, C 1146 Route 28,South Yarmouth. MA 02664
R E 3• 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued D f1 O i 5 j
JUL 25 2022 Expiration Date L. /3 I T
BLDING DEPARTMENT50.00
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By:
TRENCH PERMIT
Pursuant to G.G.c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
fins PERMIT MUST/� BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant /1 7 �4 p, V(L r /6 1 J/' , Phone v� v ""� V"�„�"V Cell
Street Address�4 C�&Cat- worn . 132 os-ae
car� �, MA OZc4 g
Name of Excavator(if different from applicant) Phone
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Street Address
City/Town j MA I ZIP
Name of Owners Property Phone
i-leira- Foe d Cisrptail61A Cell
Street Address / ,/
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Ckyfrown MA ZIP
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Other Contact
Descriptio4 location and purpose of proposed trench:
Please describe the exact location of the proposed trench and its purpose(include a descri
be laid in proposed trench(es;pipes/cable lines etc..)Please use reverse side if additional space is of whet
(or b intended)to
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Insurance Certificate lit W A 00 1
Name sad Contact informetIon of insurer:
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don Date. - w�
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Name n dJs- c ,., 'w 6 ►�ti �, , a.0 -3) d / (/
1 ' Crr piton,Penn t by S20 t:M*7.62i: 7
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Masandiusetta Hoisting License# i 41 co
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License Grade: C A; ID _Expiration Date t)
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BY SIGNING THUS 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 WORE PROPOSED,INCLUDING OSHA REGULATIONS,
G.L. c. S2A, 521 CMR 7.01 et se¢, 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, AUTHOR IZFS 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 BOLD 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.
/h'' l if T SIGNATURE
►A LA i. " ti
1 DATE w
. A ': t IGNATURE( f DIFFERENT)
`iiii*� DATE1 '�— T,l.
t ATURE(IF D
► ' ) I'. �c I A I _DATE: 1 �LI-!L I"
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