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HomeMy WebLinkAboutBLDTR-22-07516 TOWN OF YARMOUTH '� BUILDING DEPARTMENT Permit Number rZ�`' 75/�a. p(- i'`g y 1146 Route 28,South Yarmouth,MA 02664 ,~ �.0 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued Expiration Date 5' 50.oa TRENCH PERMIT E E i V E D Pursuant to C.L.c. 82A *I and 520 CMR 7.00 et seq.(as amended)JUN THIS PEAM MUST 8E FULLY COMPLETED PRIOR TO CONSIDERATION ? R __ N 2 Z Z Name of Apptkant 9 0; r ntiG Phone 508 Ceu - ENT Street Address --f 1 C PAOup .A ioiLla Cii y/rown MA ZIP 0 a 6--; t-- MINIMENE Naar of Excavator(if different from applicant) Phone Cell Street Address CityfFown ill ZIP IIIIIIIIIIIIIIIIII Name of Owners)of Property f Street Address b ejed iminiiiiniiiIIINIIIIM Other Contact Permit Fee Received No Description,location and purpose of proposed trench:Please Yes be laid in proposed the exact location of the proposed trench and its purpose(Include a descri Nroposed trench lea;pipes/cable lines etc..)Please use rcrene ride it additions!space Is ption ofwne ht isa toris intended)to A--90,te itAillyta.C>k "IYVIA,V biCtr,fitAl'' 0\1, ,QZ1i5 (41/14MX. ""t aii sko..a..Q., . • insurance(ertiflcats K: ` 5 - Name end Contact Information of ensurer ' j Poi Es,iration D I - I ��//Bur: y� a.Dies Safe It: twaa f Name of Competent Person d`by 20 C it 7.02 1 ► 0 ` I oft IMaa rchusetts Hoisting License/ i © I . l iaa License Grade: 1 L 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 WORK, WILL BECOME FAMILIAR WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS, G.L c. S2A, 52$ CMR 7.00 d 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 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 TIDE PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES TARN 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. APPLICANT SIGNATURE J idi CZ . 1 DATE 6/c9,1 EXCAVATOR SIGNATURE(IF DIFFERENT) DATE OWNER'S SIGNATURE(IF DIFFERENT) fer.e& DATE: tsar illyasarei awl-tlrt clot'Me !tii nepVID � I1� AL/Zr Date Aw Lae 2 of 2