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Home My WebLink AboutBLDT-23-2135 A;rhentisign ID:14989248-7DA9-4B4E-B131-DADF5A6E7CC7 SOWN v1.1010ISri BUILDING 1 lN(: DEP kit! MEN I. Permit Number 3a71 3--2J3S' � y _ 146 ltt/ttle 2S. Smith 1 artttoutb. Oi \ 026114 ��', �. .• •Zi -"IS-'s'TS-72.3I is 2(1I Fax •(lS-.?')�-(t5;(1 Date Issued Expiration Date TRENCH PERMIT Pursuant to GA,. c. 82A §1 and 520 CMR 7.00 et seq.(as amended) THIS PERMIT MUST HE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant 1;,-, a re; (•c,1$) Phone Cell Street A1lttresx 310.ot (' OI . i cityrrown I MA ZIP Name of Excavator(if different from applicant) Phone ('ell Street .Address City/Town MA ZIP Name of Ownerts)of Property Phone {'ell Street Address n k )11 city/Town MA ZIP \Pcl- s rrvic,vjJ1 L 6- 1 3 Other Contact Permit Fee Received No( I 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 for is intended)to be laid in proposed trench teg; pipes//cahle lines etc..)Please use reverse side if additional space is needed. • RECEIVED DEC 19 2023 BUILDING DEPARTMENT By: Insurance Certificate tt: Name and C'onta(t Information of Insurer: , fit C �� I �>. )y'o' 31 > Sc i Policy Expiration Date:— 3«! Dig Safe N: Name of(ompetent Person tas defined by 520('MR 7.02t I11 1 ot2 Ar4ientisign ID:14989248-70A9.4B4E-B131-DADF5A6E7CC7 y .. M>tssxtcltt>setts Hoisting License M 7 3 License Grade: r y( Expiration Date: BY SIGNING THIS FORM. THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMMENCF.MENT OF THE WORK,WILL BECOME FAMILIAR WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS, C.I.. c. 82A, 520 CMR 7.00 et seq.. AND ANY APPLICABLE MUNICIPAL ORDLNANCES, BY-LAWS AND REGULATION'S 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, 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 LNCURRED BY TILE MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER, INCLUDNNI,,BUT NOT LIMITED TO ENFORCING ORCING 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 THUS PERMIT. APPLI 'ANT SIGNATURE DATE / , " / -- 1 3 EXCAVATOR SIGNATURE(IF DIFFERENT) DATE OWNER'S SIGNATURE(IF DIFFERENT) anth y.Ji.(wafhn 1 211 7/2 0 2 3 �_ DATE: -2:17/2023 4:22:44 PM EST AuthenhstGN' .i twda S.eawathe 12i 1712023 4:21:37 PM EST For C NstI uM n write,r is thi%section i PERMIT 1PPROEEDHt ._,�. PERSIICTl\t. tt'IHORH- _- Date CONDITIONS OF iI'f'R(l1 lt. _� _..__.___. Y _— 2of2 Commonwealth of Massachusetts Division of Occupational Licensure HoestnCji 06-(rer HE-028673 Y' Spires: 12/30/2024 LAURENCE 67.ELLIS JR F 8 NORTH ST!, DENNIS PORtMA 02639 Commissioner (1I t K. YE" Hoisting Engineer Restricted to: HE-2A-Excavators DIG SAFE Call Center:(888)344-7233 In case of accident call: (508)820-1444 Contact OPSI:(617)727-3200 or visit www.mass.govldpllopsi AccoRc, CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYY) 6/7/2023 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 CONTACT RogersGray,A Baldwin Risk Partner NAME: ROgerSGfay-SBC PHONE 781_208-8400 FAX 410 University Ave (Nc,No,Ext): (NC,No): Westwood MA 02090 A E-MAILSS: RGSBC@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC S License#:PC-514062 INSURER A:Associated Employers Insurance 11104 INSURED REID&LA-01 INSURER B:West American Insurance Co 44393 Reid&Laurence Ellis dba Ellis Brothers Construction 23 Enterprise Rd, P.O.Box 59 INSURER c:Arbella Protection _ 41360 Yarmouthport MA 02675 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1331793718 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS 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 TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP I LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY)a LIMITS B X COMMERCIAL GENERAL UABIUTY BKW58371201 3/1/2023 3/1/2024 EACH OCCURRENCE $1,000,ODO CLAIMS-MADE X OCCUR DAMAGETO—RENTED PREMISES(Ea occurrence) $100,000 MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 PRO- X POLICY JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ C AUTOMOBILE LIABILITY 1020002607 6/9/2023 6/9/2024 jEa COMBINaccident)ED SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $250,000 OWNED X SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $500,000 X HIRED X NON-OWNED PROPERTY DAMAGE $100,000 AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE — - AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WCC-500-5000706-2022A 12/3/2022 12/3/2023 X PER ERH AND EMPLOYERS'UABILITY Y/N ANYPROPRIETORIPARTNER/EXECUTIVE -- OFFICERlMEMBEREXCLUOED? N l A E.L.EACH ACCIDENT $100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE 100,000 If yes,describe under _ $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth MA 02664 AUTOAAWFDREPRESENTATIVE t ". O 1988-2015 ACORD CORPORATION. All rights reserved ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD