HomeMy WebLinkAboutBLDTR-23-000803 TOWN OF YARMOUTH
Permit Number 13(i)172-Z3-COL)
BUILDING DEPARTiVIENT
1146 Route 28,South Yarmouth, MA 02664
508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
Expiration Date Li-A. -1 LP-7 le
'. I I II
" ECEIVED
TRENCH PERMIT fl
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as awe i )AUG .1 2 2022
FHIS PER.Mff MUST BE FULLY COMPLETED PRIOR TO CONSIMA IT t
BUILDING DEPARTMENT
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Name of Applicant Vo.c.,\ c_ mc\-;r\ Phone Cell —
C-Q_i)\-' ( 0 '.--)C-0-V-,K, '-.)LA v`,"L C.` Z..•(..
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Street
Address - -
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:''.5() S))6k,'IC :3$•\
City/Town MA ZIP
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Name of Excavator li(different from applicant) Phone Cell
Street Address
City/Town MA I ZIP
(*lame of°wiser-is)id Property -'.. e Phone Cell
Street Address
/7 , 55-&---A-
City/Town 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 a description of what b(or Is intended)to
be laid In proposed trench(eg;pipes/rade lines etc..)Please use reverse side if additional space Is needed.
- — --- ,,,Ce-delera— i 1/-7- 7'er•• ••e-j" e...74"
.
Insurance Certificate at
1 P)00160C1 illict99
M ems and Contact Information of Insurer: 'OccA( _
I P zo(..,A. ock0 \-\1( - tj,,z) 1-\c- ..p(
_____...
Pulley_F.spirstinn Date: n 0430
Y, Di,Safe 0:
I ,-.-A Ciat3 — ?)1^.0 IL)ai, Name et Competent Penne I as defined hy 52D(MR 7 in):
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Afate.diusetts Hoisting License Ii 1 E 06acC5-1
' License Grikdo i C.j ..),C-), Dk.:-.
Expirstlon Date: */ ''.. %/ 29
BY SIGNING Tiu FORM. THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH,OR, BEFORE COMMENCEMENT OF THE WORJK, WILL BECOME FAMILIAR
WITH,ALL LAWS AND REGIJLATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,
CL e. SU, 520 (MR 7.0111 et seq., AND ANY APPUCABLE MUNICIPAL ORDINANCES, BY-LAWS AND
REGLIATMS 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, AUTHORI7ES PERSONS DULY APPOINTED BY THE mumapAury TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE
CONDITMS ATTACHED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH WORK
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AG' ! JOINTLY AND SEVERALLY TO
REIMBURSE TILE 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 UNITED TO ENFORCING THE • • 0 ' ENTS Or STATE LAW AND CONDITIONS OF
THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWTTH,AND ' .4 ' ; TAKEN BY THE
MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO
COMPLY THEREWTTII 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 ' ' Z4 SES RESULTING FROM OR ARISING OUT
OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNA17.1RE
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EXCAVATOR SIGNATURE (IF DIFFERMT)
DATE
OWNER'S SIGNATURE (IF DIFFERENT)
___ DATE:
Foe CRIMeine see—Do not Twilit di
A' ArrilOVID ali
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