HomeMy WebLinkAboutBLDTR-23-000805 TOWN OF YARMOUTH
,oF � �o` BUILDING DEPARTMENT L���Z �3-���
O � RTMENT Permit Number
y 1146 Route 28,South Yarmouth, MA 02664
508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
Expiration Date
odu—irtfi- e_04-c) $50.00
TRENCH PERMIT
' rsuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applkan 4r511 C "'cis,
Phone Cell
Street Address 21
Email Address: ° 8 —
City/Town I� ZIP
Name of Excavato (if different from applicant)
Phone Cell
Street Address R E
EIV ,: D
Email Address:
City/Town MA ZIP
Name of Ownerls) �'f Property rAA BUILDLNG DEPA: c NT
1 r.s ` h Phone Cell
Street Address A
dip
Email Address:
City/Town MA ZIP
Other Contact Permit Fee Received No ) Yes ►
Description,locatio, and purpose of proposed trench:
Please describe the e act location of the proposed trench and its purpose(includes description of what is(or is intended)to
be laid in proposed t nch(eg; pipes/cabk lines etc..)Please use reverse side if additional space is needed.
r 41 W c� O �\r c.23 . _, LtA-21-
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Insurance Certificate#: III), 1
Name and Contact Information of Insurer:
—Tet- -(. - 0
Polk Ex.iration Date: QZ �-tr�+�
Dig Safe N: zQ 7 —
Name of Competent Person(as defined by 520 CMR 7.02):
Cooklut . ii:L to
Name of Competent Person(as defined by 520 CMR 7.02):
Massachusetts Hoisting License#
License Grade: 1 Z- Expiration Date: 5 Zq
BY SIGNING THIS 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 WORK PROPOSED,INCLUDING OSHA REGULATIONS,
G.L. c. 82A, 520 CMR 7.00 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 GOVERING 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 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
OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
PLICANT IGN URE1
DATE leAto
EXCAVATOR SIGNATURE (IF DIFFERENT)
DATE
OWNER'S SIGNATU'F (IF DIFFERENT)
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'" ` - ' DATE:
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