HomeMy WebLinkAboutBLDTR-22-007519 TOWN OF YARMOUTH B 1k — 7S I
BUILDING DEPARTMENT Permit Number
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k 1146 Route 28,South Yarmouth, MA 02664
Hta; M IA 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued
Expiration Date
OIVED
TRENCH PERMIT
Pursuant to G.L.e. 82A §I and 520 CMR 7.00 et seq.(as amendedFt-JO 281022
MIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDER I1ON eyBUILDIN,:3 DtPARTMENT
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Name of Appikant t 6bc.-/I G . oe.1,� !prom col n — __
Street Address "Z - `�^
363 (frtTES' PA-rtt Stag- (77 2g17
City/Tawn ,tA I ZIP
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Name of Excavator(if different from applicant) Phone Cell
Street Address
City/Town I MA r ZIP
Nast of Ownerlsl of Property Phone Cell
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Street Address
1473 PottliKArANAltkor Dk.,
Cltyfrown 1 MA ZIP
"3 .- VA C)Cal 1 _ C.
Other Contalet I Permit Fee Received No( ) Yes( )
Description,tocetioe and purpose of proposed trench:
Please describe the exert location of the proposed trench and its purpose(Include a dtacriptka of what Is(or is intended)to
be laid in proposed trench(e*:pipes/cable lines etc..)Please use reverse side if additional apace is needed.
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Insturenct Certilpcats tt= C 150Icos, '_3o
'lame and Cowart Information of Irountrt
Pinky Elgirstkm Date: (Z--L- 2-0 Z,.:2-,
Dig Safe il:
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IName of Competent Perron(as defined by 520('MR 7.112):
1MA01 (06- 42,64,-/
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khze.AcEusetts Misting License M H `" 1 S 6 4.61-
' License Grades E-'-).4 Expiration Date: i i- S - ;-6;�.-D.‘
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.
C.L. c. 02A, 52r CMit 7,00 ea seq., AND ANY AMICABLE 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 WTTA 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
THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES TAKEN BY THE
MUNICIPALITY TO PROTECT TIDE 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,
INDEMN FY,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
OP ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APPLIC 51 7,,,,,.4)7e2._____A REi
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EXCAVA SDGNA we DIFFERENT)
tie� DATE /�- 2. - 2-02Z
NERIGNA-TURE TUIP`DIFFERENT)
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