HomeMy WebLinkAboutWorkers' Compensation Certificate - BLDT-23-2132 29810Permit Number
Date Issued
Expiration Date
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Pursuant to G.L. c. t2A !l and 520 CMR 7.00 et scq.(as am
THIS PEB.TIIr ITUST BE FULLY COMPLETED PRIOR TO CONSIDENA
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TOWN OF YARMOUTH
BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, MA 02664
508-398-2231 ext- 126l Fax 508-398-0836
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Name of Competent Person (as defrned by 520 CMR 7.02):
Massachnsetts Hoisring License # ll€ - tO f at {
License Grade:n Date:
BY SIGNING TIIIS FORM, TEE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTITTTHAT TIIEY ARE FAMILIAR WT[H, OR, BEFORE COMMENCEMENT OF TI{E WORK, WILL BECOME EAMILIARWTIH, ALL LAWS AND REGI'I-ATIONS APPLICABLE TO WORK PROPOSED, INCLUDING OSIIA REGTJLATIONS;G.L. c. 82A, 520 cMR 7.00 et seq., AND Ati-Y APPLICABLE MLTMCIPAL oRDINANCES, By-LAws ANr,REGULATIONS AND TIIEY COVENANT AND AGREE THAT AIL WORK DONE TJNDER TIIE PERMIT ISSUED FORSUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITII TIIE CONDITIONS SET FORTHBELOW.
TIIE TTNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMTT AND TTIEEXCAVATOR TO T]NDERTAIG SUCH WORK ON TIIE PROPERTY OF TIIE OWI\,E& AND AI-SO, FOR TIIEDURATION OF CONSTRUCTION, AUTIIORIZES PERSONS DULY APPOINTED BY THE MT]]VCIPALITY TOENTER T]PON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONT'ORMITY WITH THECONDITIONS ATTACIIED HERETO AND TIIE LAWS AND REGULATIONS GOYERING SUCH WORK.
TIIE T]NDERSIGIIED APPLICANT, OWI\iER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TOREIMBIJRSE TIIE MT]IICIPAI,ITY FOR ANY AND ALL COSTS AND EX?ENSES INCURRED BY TIIEMUMCIPALITY IN COI\IIECTION WITH THIS PERMIT AI\'D TIIE WORK CONDUCTED TIIEREUNDER,INCLUDING BTIT NOT LIMITED TO ENT'ORCING TIIE REQUIREMENTS OF STATE LAW A-I[D CONDITIONS OFTHIS PERMIT, INSPECTIONS MA.DE TO ASSURE COMPLIANCE THEREWTTH, AND MEASURES TAKEN BY TIIEMUNICIPALITY TO PROTECT TIIE PUBLIC WHERE THE APPLICANT OWNER OR EXCAYATOR IIAS FAILED TOCOMPLY TIIEREWTIH INCLUDING POLICE DETAILS AIID OTI{ER REMEDIAL MEASURES DEEMEDNECESSARY BY THE MUNICIPALITY.
TI{E UNDERSIGNED APPLICANT, OWNER AND EXCAYATOR AGREE JOIMLY AND SE'IIERALLY TO DEFEND,INDEMNIT"T, AND HOLD EARMIJSS THE MIJNICIPALITY AND ALL oF ITS AGENTS AND EMPLOYEES FROMAIry AND ALL LIABILTTY, CAUSES OR ACTION, COSTS, AND E)PENSES RESULTING FROM OR ARISING OUTOF ANY INJIJRY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DT]RING T}IE WORKCONDUCTED TINDER TIIIS PERMIT.
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