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HomeMy WebLinkAboutBLDTR-22-007520 TOWN OF YARMOUTH BLS 1[2 ZZ- 7SZ) o:44- BUILDING DEPARTMENT Permit Number Io( 014 y 1146 Route 28,South Yarmouth,MA 02664 ~ i 3„�oz', 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued R E E D Expiration Date $50.00 BUILDING DEPARTMENT TRENCH PERMIT By --- -- nt 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 Applicant Robert B Our Co., Inc. - PhoneCell Streit Address 24 Great Western Rd 508 432-0530 978 895 5115 City/Town MA ZIP Harwich 02645 Name of Excavator(if different from applicant) Phone Cell Street Address City/rown MA ZIP Name of Ownerisi of Property Phone Cell Dennis-Yarmouth Reg School District Street Address 296 Station Ave City/Town MA ZIP So. Yarmouth 02664 Other Contact 1 Permit Fee Received No l ) 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 lines etc..)Please use reverse side ifadditional space Is needed. Installing Traffic Lights at the entrance to the admin building at 296 Station Ave. Electrical conduit will be placed in trench. Insurance Certificate 0= CPA130128-30 Name and Contact Information of Insurer: 1 Hub International New England Catherine lawrence 508-235-2207 Policy Expiration Date: 12.1.22 ,-- I Dig Sate 20222004554 Name of Competent Person tan defined by SIA CM&7.U2): Jeremy Walsh 1of2 Massachusetts Hoisting License 1 H E-137079 • License Grade: Hoisting engineer _ Expiration Date: 02/16/23 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. e. S2A, 5211 CMR 7.01 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 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 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 f DATE 6/8/22 EXCAVATOR SIGNATURE(IF DIFFERENT) DATE OWNER'S SIGNATURE(IF DIFFERENT) DATE: Par CltlITaws No-[#e at weft b t!iordee ruaurruwd Avg r �••CONINTiON 01A/M _ 2of2 /�,,,, ROBEBOU-01 MVERTENTES A� Q DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 11/30/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER License#1780862 CONTACT NAME: Catherine Lawrence HUB International New England PHONE FAX No,Ext):(508)235-2207 (A/C,No): 222 Milliken Boulevard Fall River,MA 02721 ADDR E-MAIESS:catherine.lawrence@hubinternational.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Firemen's Insurance Company of Washington,D.C. 21784 INSURED INSURER B:Acadia Insurance Company 31325 Robert B Our Co.,Inc. INSURER C:Navigators Insurance Company 42307 24 Great Western Road INSURER D P.O.Box 1539 Harwich,MA 02645 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO ERIFY THAT THE INDICATED. CNOTTWITHSTAND NG AONY REQUIREMENT,LICIES OF H TERMNCE I OTR CONDITION ED BELOW AOF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT VE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE TOLWHICH TICY HIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR LIMITS TYPE OF INSURANCE INSD WVD POLICY NUMBER IMM/DD/YYYY) IMM/DD/YYYY) 1,000,000 A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE X OCCUR X CPA1301428-30 12/1/2021 12/1/2022 DAMAGETORENTED 1,000,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 20,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 2 000 000 POLICY PROT LOC PRODUCTS-COMP/OP AGG $ JEC OTHER: $ COMBINED SINGLE LIMIT $ 1,000,000 A AUTOMOBILE LIABILITY (Ea accident) X ANY AUTO MAA1301440-30 12/1/2021 12/1/2022 BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS PROPERTY DAMAGE HIRED NON-OWNED (Per accident) $ AUTOS ONLY AUTOS ONLY $ EACH OCCURRENCE $ 7,000,000 B X UMBRELLA LIAB X OCCUR EXCESS LIAB CLAIMS-MADE CUA 5460543-11 12/1/2021 12/1/2022 AGGREGATE $ aggregate $ 7,000,000 DED RETENTION$ A WORKERS COMPENSATION y PER X STATUTE OERH AND EMPLOYERS'LIABILITY Y/N WPA0316767-22 1/1/2022 1/1/2023 500,000 E.L.EACH ACCIDENT $ O PROPRIETOR/PARTNER/EXECUTIVECLDE N N/A 500,000 OFFICER/MEMBERat EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ If E N under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below 9,000,000 C Commercial Umbrella GA21EXC8887101V 12/1/2021 12/1/2022 each occ/aggregate B Equipment Floater CIM5182149-17 12/1/2021 12/1/2022 Each occ/aggregate 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re:Trenching Permit Certificate holder is named as additional insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIONXP WITH THEPOLICY TE THEREOF,O NOTICE WILL BE DELIVERED IN Town of Yarmouth. S. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE .9, yK I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: ROBEBOU-01 MVERTENTES LOC#: 0 ACORO ADDITIONAL REMARKS SCHEDULE Page 1 of 1 License#1780862 NAMED INSURED AGENCY Robert B Our Co.,Inc. HUB International New England 2 o Box 15 tern Road POLICY NUMBER PHarwich,MA 02645 SEE PAGE 1 CARRIER NAIC CODE SEE PAGE 1 SEE P 1 EFFECTIVE DATE:SEE PAGE 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance ***Additional Policies*** Contractors Pollution Carrier: Illinois Union NAIC#33667 Policy#CPYG27416676004 Term: 12/01/2021-12/01/2023 $2,000,000 Each Occl$2,000,000 Aggregate- Motor Truck Cargo Acadia Insurance Co Policy#CIM5182149 term: 12/01/2021-12/01/2022 Limit$500,000 Per Conveyance Installation Floater Acadia Insurance Co Policy#CIM5182149 term: 12/01/2021-12/01/2022 Limit$300,000 Per Jobsite Deductible$5,000 Professional Liability Ironshore Specialty Insurance Co Policy#DCP7BABOPFQ002 term : 12/01/2021-12/01/2022 $2,000,000 Each Claim/$2,000,000 Aggregate ©2008 ACORD CORPORATION. All rights reserved. ACORD 101 (2008/01) The ACORD name and logo are registered marks of ACORD 1 Commonwealth of Massachusetts \.....: Division of Professional Licensure H - , ' er HE-137079 -_ ires; 21f/203 JEREMY D IA/Ai-Sit N'ilil, T VICTORIA Frp 104 HAR1NH li ,�'" 0 s - 'Ill , Commissioner i �0 K. bicendisk, Town of Yarmouth DATE Department of Public Works RE WE ROAD OPENING PERMIT t Pursuant to the Town of Yarmouth requirements and applicable provisions of Massachusetts General Laws,the undersigned respectfully requests that your written consent be given to excavate and/or tunnel under the ground in the following Town/public/private way(s)for the following purposes: LOCATION: g(.p 3'4+1 to ' h)(•&) flLWH1 LOT#: c2 POLE#: PURPOSE: . .r �{�VG 'IC Siqntac Proposed depth of cut: .5_feet (NO : if 3'or deeper cut is proposed,then you may also need to apply for a Trench Permit from the Yarmouth Building Department--see more below,) The undersigned agrees to conform to all applicable federal,state,and local laws,by-laws,regulations (e.g.,OSHA),and guidelines,and to abide by all stipulations of and attachments to the Permit. In addition,the undersigned agrees by the acceptance of this Permit to: be responsible for all acts in connection with this Permit; have appropriate insurance coverage for any injuries to persons or property;indemnify the Town of Yarmouth for any of its acts in connection with this Permit;and,be responsible for trench excavation and maintenance during the period of construction as well as trench repairs caused by settlement and/or poor construction for a period of one year from the date of project completion. CONTRACTOR: Pnbed .ate( 2 Jne PHONE; 5b -c-'3 OS 3b ADDRESS: c J (q4(-Pd-- W. rn i?c( CONTACT: lt/n U)l SA'2 hALJ.l&tl, f a. s- SIGNATURE: PAVEMENT CUTS ALLOWED CYYE NO INFRARED REQUIRED YES NO SPECIAL CONDITIONS/ATTAC NTS: • h rn 4 i.t5TE-&!-ON/7/0r� 5 4t° a31$3 aa • Massachusetts State Law(MGL c.82A s.1 and 520 CMR 7.00 et seq)requires that an excavator obtain a"Trench Permit"from the Town of Yarmouth prior to digging a trench on public or private land or within public or private ways. A"trench"is defined in the regulations as"An excavation,which is narrow in relation to its length,made below the surface of the ground in excess of 3 feet and the depth of which is,in general,greater than the width,but the width of the trench,as measured at the bottom,is no greater than 15 feet." A trench permit application can be obtained at the Building Department located at the Yarmouth Town Offices at 1146 Route 28 in South Yarmouth. • An materials and construction methods shall meet Massachusetts Highway Department's Standard Specifications,as amended herein. • Permittee shall call DIGSAPE and the Yarmouth Water Division(508-771-7921)at least 72 hours prior to initiating any work. • Only one half of the road may be closed at any one time,at least one travel lane shall remain open to traffic flow,and adequate police direction(paid by Permittee)shall be provided, Continued next page. I of 2