HomeMy WebLinkAboutBLDTR-22-007466 -;'"--;;--, TOWN OF YARMOUTH mi-f k 1-( 11/4.12
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k � BUILDING DEPARTMENT
�" o N I' Permit Number 6L1�`�J�.-�-,3-_
ig, , C 1 146 Route 28, South Yarmouth, NIA 02664
?\ ` ` yy(tt 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued 0 17c-rl'&
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�����J Expiration Date nil # cr3 3
$50.00
TRENCH PERMIT RECEIVED
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amenCedr ��-
riffs PERMIT
MUST BE FULLY COMPLETED PRIOR TO CONSIDERAT►O11 JUN 2 3 2022
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Name of Applicant i/ >I p CJ1"U te Cell BUILDING DEPARTM1T
Street Address -3Z
-grAtrup:2 atito 500-5o1 - 12,5, ....,_
City/Town NIA ZIP
Name of Excavator Of different from applicant) Phone Cell
Street Address
City/Town MA ZIP
Name of Owner(s)of Pro-pee 12. -.,^r] 1..tvaLl.) Phone Cell
Street Address s Flo y
City/Town MA 1 ZIP
. i.revi444(ziv 0)14
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Other Contact 1 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 is(or is intended)to
be laid in proposed trench(es;pipes/cable Hoes etc..)Please use reverse side if additional space is needed.
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Insurance Certificate f:
Name and Contact Ink rmation of Insurer:
i t It6u/MAICt Vie.. o 4uaE ,(
1
Policy Expiration pate: « ICI 20Zyr✓ y, �9 ('�(��7
1 Did Safe N: �14,1 k )� v 1 �J��Vl� !/t1i. f '�j
Name of Competent Person(as o reed by 52D CMR 7 t)2►: S ` ?j �"'
—` ,IC J 6) '1W6`r 1'/ Ji✓l./
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f Maaachusett s Hoisting License F 6Z
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License Grade: c �6C`2� - 4y
Expiration Date: c� 2-I
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 WORE PROPOSED,INCLUDING OSHA REGULATIONS,
G.L a 8'2A, 520 CMR 7.00 et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND
REGULATIONS AND THEY COVENANT AND AGREE THAT ALI. 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, THE OF CONSTRUCTION, AUTHORI7.FS PERSONS DULY APPOINTED BY THE MUNICIPALITY FORALITY 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.
CANTS '
DATE 14
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER' SIGN,"T'URE(IF DIFFERENT)
DATE.
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