HomeMy WebLinkAboutWorkers' Compensation Certificate - BLDT-23-2133 29816TOWN OF YARMOUTH
BUILDING DEPARTMENT
1146 Route 2E, South yarmouth, MA 02664
508-398-2231 ext. 1261 Fax 50&398-0836
Permit Number
Date Issued
Expiration Date
$50.0
TR"EN'CH PERMIT
hrrsuent to G.L. c. t2A Sl and 520 CMR 7.fil et scq.(as
Iltlli PENMIT MUST 8E FUIIY COMPLEIf,D PR()R TO CONSTDENA
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Name of Person (as defined 520 CMR 7by.02)
Massachusetrs lloistiry License # If6.2o5f,7!-
License Grade:I
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BY SIGNING TIIIS TORM, TIIE APPLICANT OWNER,AND EXCAYATOR ALL ACKNO WLEDGE ANDTHAT TIIEY ARE FAMILIAR WTTH, OR, BEFORE COMMENCEMENT OF TIIE WORK, WILL BECOMEWITH, ALL LAWS AIYD R,EGUI.A TIONS APPLICAS LE TO WORK PROPOSED,INCLUDING OSIIA REG TIONS,G.L. c. E2A,520 CMR 7.00 et seq., AND ANY APPLICAB LE MTIMCIPAL ORDINAN CES, BY-LA ANDREGULATIONS AND TIIEY COVENANT AND AGREE THAT ALL WORK DONE TJND ER TIIE PERMIT FORSUCH WORK WILL COMPLY TIIEREWITH IN ALL RESPECTS AND WTrII TIIE CONDMIONS SET FORTEBELOW
TIIE UI{DERSIGNED OWNER AUTIIORIZES TIIE APPLICANT TO APPLY FOR TIIE PERMIT TI{EEXCAVATOR TO UNDERTA]G SUCE WORK ON TIIE PROPERTY OF TEE owNE& ArlD Arf o R TIIEDURATION OF CONSTRUCTION, AUTEORIZES PERSONS DULY APPOINTED BY TEE MLNICIP TOENTER UPON TEE PROPERTY TO MONITOR AND INSPECT TIM WORK FOR CONTORMITY TTTECONDITIONS ATTACIIED HERETO AND THE LAWS AND REGULATIONS GOYERING SUCH WORI<.
TIIE UNDERSIGIIED A}PLICANT OWNER AI\D EXCAVATOR AGREE JOINTLY AND SEVERALLY TORMMBURSE THE MLNICIPAIITY FOR ANY AND ALL COSTS AIID EXPENSES INCURRED BY TIIEMUNICIPAIITY DI CONNECTION }ITTH THIS PERMIT AND TEE WORIi COIYDUCTED THEREUNDER,INCLUDING BUT NOT LIMITTD TO ENT'ORCING TIIE REQUIREMEMS OF STATE LAW AND CONDITIO o['TITTS PERMIT, INSPECTIONS MADE TO ASSURE COMPLIANCE TIIERE}ITTH,AND MEASURES TAKEN TIIEMUNICIPALITY TO PROTECT THE PTTtsLIC WIIERE THE APPLICANT O B
COMPLY TMREWITH INCLI-]IDING WNER OR EXCAVATOR HAS F TO
NECESSARY BY THE MUNICIPALITY.
POLICE DETAILS A\D OTIIER REMEDIAL MEASURES DEEMED
THE UNDERSIGI{ED APPLICANT, OWNER AIID EXCAYATOR AGREE JOINTLY AND SEVERALLY TOINDEMNIT"T, AND IIOLD HARMLESS TIIE MUNICIPALITY AND ALL OF' ITS AGENTS ANDANY AND AIL LIABILITY, CAUSES OR ACTION, COSTS,AND EXPENSES RESULTING TR
EMPLO FROM
OF ANY INJTJRY,DEAIII, LOSS, OR DAMAGE TO OM OR OUT
CON'DUCTED UNDER THIS PERMIT.AI\[Y PERSON OR PROPERTY DI,RING T}IE WORK
APPLICANT SIGNATURE
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