HomeMy WebLinkAboutBLDTR-22-007518 " TOWN OF YARMOUTH
13' - `� BUILDING DEPARTMENT Permit Number 2"Z`C 7S/cc
- O y 1146 Route 28,South Yarmouth, MA 02664
'°^y �_�� 508-398-2231 ext. 1261 Fax 508398-036
4,4 - 8
4 .oyitD� d Date Issued
Expiration Date
50.00
TRENCH PERMIT RECEIVED
Pursuant to G.L. c. 82A *1 and 520 CMR 7.00 et seq.(as amende, )
THIS PERMIT MUST HE FULLY COMPLETED PRIOR TO CONSIDERATION
J � l
Name of Applicant
K00 (f) O Phone Cell = • • •RTMENT
Street Address `�C�2..t � ''7 `. _ j
•
t �,7 774
City/TownEmail Address: (iE(t_4
MA ZIP
5. Att&). t- OF Name of Excavator(if different from applicant)
Phone Cell
Street Address
City/Town own Email Address:
111A ZIP
Name of Ownerls)of property
. e..10 L 16 Phone Cell
Street Address
/�
3 1/ls i [ T Email Address:
City/Town :CIA ZIP
7tt l
Other Contact
Permit Fee Received No 1 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 is(or is intended)to
be laid in proposed trench(eg; pipes/cabk Tines etc..)Please use reverse ride if additional space is needed..
Insurance Certificate it: 1'3 6 2 y '
Name and Contact Information of Insurer:
HQ ij-r6RA,14-novoitc, p;E.
Policy Expiration Date: j•Z. ( LC/ZZ
Dig Safe N:
Name of Competent Person las defined by 520 CMR 7.G2):
_C 1
•
Maauichusetta Hoisting Lkense 0 a
License-
icen Grade: f4 I`{
Ex 'ration Dare: i �C r G:•4--:),.
BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF THE WORK,
BECOME FAMILIAR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLINGSHA REGULATIONS,
G.L c d2A, 520 CMR 7.00 et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES,
REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED
AND
SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND W ISSiJED FOR
BELOW. THE CONDITIONS SET FORTH
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 WORK
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REIMBURSE THE MUNICIPALITY FOR ANY AM)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 TILE MUNICIPALITY.
THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDEMNIFY, AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS
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.
APPLIC `SI NA RED
Kr -- -
L: DATE ' ' c 02:2—
EXCAVA OR/SIGNA RE(LE DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
Colleen (Courtney) Cronin
DATE: June 24, 2022
r !!Y Fur City/f —Dr met*Ma 10 ME
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