HomeMy WebLinkAboutBLDTR-22-007273 71 ki at. zp/zz
TOWN OF 'VAR NIOLITIF
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- BUILDING DEPART!‘'ENT
Permit Number gt,/, 7 _
1146 Route 23. South l'arottouth. Al. 02664
503-398-2231 e :50
xt. 261 Fax 8-398-0836 Date Issued
Expiration Date 6,L4/ I
RECEIVED
TRENCH PERMIT
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as a4etdeThN 1 7 2022
THLS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERA DEPARTMENT
By:
Name of Applicantc)u\cvc3 jc‘\\cc\ Phone Cell
Street Addrem -71 -3C-11—`00C-*5
-S. GOL_ CNC\
City/Town MA ZIP
e.3\c 01(014--%
Name of Excavator(if different from applicant) Phone Cell
Street Address
City/Town MA r ZIP
Name of Ownerts)of Property Phone Cell
ecc 163,(\(e__
Street Address
300 yv,e3\-ceek
City/Town zp
C1,`"C\ CAN
Other Contact [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(eg;pipes/cable lines etc..)Please use reverse side if additional space is needed.
k(c\e_kcee._
•
Insurance Certificate#:(0,.72sauskAkLc ) zA
Name and Contact Information of Insirer.
NXV6CC-0(\ 2 j3(,c_NN 61.)e k\ (Scs --.11S—k( C)
Policy Expiration Date: 5
Dig Safe#:
G
Name of Competent Person I as defined by 5215 CMR 7.02):
OigNOiN We\C.-\(.\
1 of 2
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/4611$1Kbillidil #
[Jams*Cowin Date 1.1s)1.---).
BY SIGIONG Tin FORM,THE APPUCANT,OWNER,AND EXCAVATOrt ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH,OR,ItEF'OREEtDIENCEIRENT OF THE WORK,WILL IIKOME FAMILIAR
will!,AU.LAWS AND REGULATIONS API TO WORK PROPOSED.INCLUDING OSTIA REGULATIONS,
G.L. c SPA, STE CMR 7.* fft aq., AND ANY APPLICABLE MUNICIPAL ORDINANCES BY-LAWS AND
REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR
SUCH WORK WILL COMPLY THEREWITH IN ALL ItESPECTS AND WITH THE GONE SET FORTH
BELOW
TEE UNDERSIGNED OWNER AUTHORIZES THE ATIPUCANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WORK ON Tilt PROPERTY OF THE OWNER, AND ALSO, FOR THE
DURATION OF CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO 110E11011 AND INSPECT THE WORK FOR CONFORMITY '‘VIIII THE
CONEV'ERINS ATTACKED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH IVORTL
INCLUDING BUT BUC:161NOTAPPULIMETEDCANTTO,OENWNIMFORA1C4I DEGEITHECA
EXCAVATOR 770:sTYATEAND:w CLLOYNDITITO oNs or
REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INC:ERRED BY THE
MUNICIPALITY IN CONNECITOPI 'THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
1115 PERMIT.INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH.AND MEASURES TAKEN BY THE
MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FARM)TO
COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL STEASIJRES DEEMED
NECESSARY BY THE MUNICIPALITY.
THE UNDERSIGNED APPLICANT.OWNER AM)EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND.
WIDENINWY,AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM
ANY AND ALL LIAIIIUTY,CAUSES OR ACTION,COSTS,AND EXPENSES RESULTING FROM OR ARISING OUT
OP ANY INJURY, DEATH, !Mt OR DAMAGE TO ANY PERSON OR PROPERTY DURING TILE WORK
CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNATURE
DATE k
EXCAVATOR DiesNAIIIRE(W DIFFERENT)
DATE
NA
°Atilt 4$' /a 341r.
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