HomeMy WebLinkAboutBLDTR-23-000638 I'm (ui)e d a1,P-102
:1 TOWN OF YARMOUTH
�, t ye a: BUILDING DEPARTMENT Permit Number 3 vb _ ,,,3_
��_ , ,� 1146 Route:.5,South Yarmouth, MA 0266d
»,,T„ „ .max• 50$-.i98-2231 ext. 1261 l ax 5f)8-398-(l836 Date Issued 0OO 6,5j
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Expiation Date (3,�g;13LJ'q tf
451144
ECEIVED
TRENCH PERMIT
Pursuant to G.L.c. 82A §1 and 520 CMR 7.00 et seq.(as amend ) AUG 03 2022
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
BUILDING DEPARTMENT
Name of Applicant 6 3 a ctx.coa\Ja oA IAL• Phone Cell 9Y. — —
Street Address 5". till-O(o 3
3lt.k ROVE 1U
City/rown MA ZIP
Soanc a. Igo,, 0ZS`3
Name of Excavator of different front appicant) Phone Cell
Street Address
City/own MA _ZIP j
Nara*of Owoerts)of Property 01101 4,1k4„, Monahan PhD11e Cell
Street Address
3 Toc1.1L Cove, Quack
City/Town MA ZIP
ll
S. 00 i L
Other Contact [Permit Fee Received No( ) Yes( )
Description Wattle.and purpose of proposed trench:
Please describe the exact location of the proposed trench sad its purpose(include a description of what is for is intended)to
be laid in proposed trench(re;pipeakable Ones etc..)Please use reverse wide if additional space is needed.
t o 51-A1,0.{i or o ';C, bIP"
Insurance Certificate O:
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Name and Contact information of Insurer
Se,le,chw tAS.
Policy F.epiratMn t)sten s j7 Z S
Di{I!i*" Z o2Z2611g8Y
Name of Competent Perna i as defined by 520 CM*.742):
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Misssehusetts Hoisting License I HE. 0q 81.o
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License Grades 7,A
_ Ezpiratba Dater
BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACLNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF THE WORK,WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,
G.L. e. VA, 5211 CMR 7.01 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 WORIG
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REIMBURSE THE MUMCIPALITY 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 CONDITII ONS 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 Y 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
Or ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APPLI T SIGN RE
DATE r'3' ZZ
EXC VATOR IGNATURE IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IP`DIFFERENT)
DATE:
Far ubtrompe 41t= est wr> r
tee
Art $21
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