HomeMy WebLinkAboutBLDTR-23-000804 Ya TOWN OF YARMOUTH 13LO 72-.3--f66&
' BUILDING DEPARTMENT Permit Number
1146 Route 28, South Yarmouth. MA 02664
508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
,-•
aA.17. r> xe-INV
Expiration Date C&(2C�,
$50.00
TRENCH PERMIT RECEIVED
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amendedj`— _ry-_ ._.__.�.._.
tHIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION AUG 10 2022
Nast!of Applicant �.� C AA 'QW Phone Cell BUILDING D EPA R Tt+n E N T
Hy
Street Address - SC78 -O 4 I zs
City/Town A ZIP
Name of Excavator(if different from applicant) Phone Cell
Street Address
Citylrown MA ZIP
Name"r!rrtsl ut��JDC- ll ,� Phone Cell
Address q t51R
care � MA ZIP
C)Z5cC=C-\
Other Contact I Perm Fee Received No( ) Yes()
Description.iocatloa and purpose of proposed trench:
Please describe the exact location of the proposed trench sad its purpose(include a description of what is(or is intended)to
be laid in proposed trench leg;pipes/cable Nees etc..)Please use reverse side if additional space is needed.
insurance Certifkate/it � z2 - 45-:=
Name and Contort,Information of Insurer:
Polity Expiration Date
Die Safe lit Z®ZL ( -!
Nance of Competent
Perna(as defined by 520pp ��
(MR 7.)2):
c%� G P c -'
I of 2
r,
a..
Mi ch Manias License I IA -1
License Graff e 4 �- Expiration Date:
BY SIGNING THIS FORM,THE APPLICANT, OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTiFy
THAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF THE
MTH ALL LAWS AND REGULATION APPLICABLE TO WORKWORE,.NG O BECOME LATIMI R
G.L. � FLit, � CMR 7.i1! et PROPOSED,t]NC"IUIItNG OSI�iA RlGULATION,
sq., AND ANY APPLICABLE E!EUNICIPAL ORDINANCES, BY-LAWS AND
REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR
SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH
BELOW.
ran UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF T$E O
DURATION OR.:CONNSTRUCTIOi AU h*OIIZES PERSONS DULYWY NO ALSO,. :POR THE
APPOINTED THEBY MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE
CONI/I TIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS GOVERN()SUCH WORK.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COWLS AND EX7t984 INCURRED BY THE
MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THERIHINDER,
INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS Ot STATE LAW APID CONDITIONS OF
THIS PERMIT,ANSPECTK)N5 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 TEMRi<WTTII INCLUDING POLICE DETAILS AND OTHER REJNEDIAL MEASURE,DEEMED
NECESSARY BY THE MUNICIPALITY.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INI MNI 'Y, AND HOLD HARMLESS TIRE MUNICIPALITY AND ALL OF ITS ACBNT3 AND EMfIAYF.FS FROM
ANY AND ALL LIA 11111 Y,CAUSES OR ACTION,COIITS,AND IC/MENSES RESULTING FROM OR ARISING OUT
OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
7,\14‘..A
CANT NA
DATE ` 5'
EXCAVATOR SIGNATURE t1F DIFFERENT}
DATE
ER SIGN . RE(IF :RENT)
DATE.. 2 22 —
L
'I i x.
rL
t ... tri.
2 of