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TOWN OF YARMOUTH
BUILDING DEPARTMENT
1146 Route 2E, South Yarmouth, MA 02664
508-398-2231 ext. 126l Fax 508-398-0836
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Expiration Date tL/eq
$50.00
Permit Number
Date Issued
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IRENCHPERMIT
hrrsrnnt to G.L. c. t2A !l and 520 CMR 7.00 et scq.(as
TI{IS PER.MIT }TUST BE FULLY COMPLETED PRIOR, TO CONSDENATIO
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Name of Competen
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r Persoo (as defiaed bv-1,--ULq/t"520 CMR 7.02):
Massachusetts lloisting Licerxe # )_l€. t i ? 1 I tl
License Grade:AoaJ-iration Date: /4 s
BY SIGNING TIIIS FORM, TEE APPLICANT, OWNER, AND EXCAYATOR ALL ACKNOWLEDGE AND CERTtr'YTHAT THEY ARE FAMILIAR WT[H, OR, BEFORE COMMENCEMENT OF THE WORK, WILL BECOME F'AMILIARWTTII, ALL LAWS AND REGTJLATIONS APPLICABLE TO WORK PROPOSED, INCLT]DING OSHA REGULATIONS,G.L. c. 82A, 520 cMR 7.00 et seq., AND AIVY APPLICABLE MLTMCIPAL 0RDINANCES, By-LAws ANDREGIJLATIONS AND TIIEY COVENANT AND AGRXE THAT AIL WORK DONE UNDER THE PERMIT ISSUED FORSUCH WORK WILL COMPLY TIIEREWITH IN ALL RESPECTS AND WITH TIIE CONDITIONS SET FORTHBELOW.
TITE UNDERSIGNED OWNER AUTHORI2MS TIIE APPLICANT TO APPLY I'OR THE PERMIT AND TIMEXCAVATOR TO UNDERTAKE SUCH WORK ON TIIE PROPERTY OF TIIE OWNER, AND ALSO, ['OR TIIEDT]RATION OF CONSTRUCTION, AI]TIIORIZES PERSONS DULY APPOINTED BY TIIE MUNICIPATITY TOENTER UPON TIIE PROPERTY TO MONITOR AND INSPECT THE WORK ['OR CONT'ORMITY WTTH THECONDTIIONS ATTACIIED HERETO AND TI{E LAWS AND REGULATIONS GOI'ERING SUCH WORK.
TIIE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE "IOINTLY AND SEVERALLY TOREIMBURSE TIIE MUNICIPALITY FOR ANY AND ALL COSTS AND EX?ENSES INCURRED BY TIIEMUMCIPALITY IN CONNECTION WITH THIS PERMIT AND TIIE WORK CONDUCTED TIIEREUNDER,INCLUDING Bt/T NOT LIMruED TO ENFORCING TIIE REQUIREMENTS OF STATE LAW AND CONDMONS OFTIIIS PERMIT, INSPECTIONS MADE TO ASSIIRE COMPLIANCE THERE\4TIH, AND MEASURES TAKEN BY TIIEMUMCIPALITY TO PROTECT TIIE PT]BLIC WHERE TIIE APPLICANT OWNER OR EXCAVATOR HAS FAILED TOCOMPLY THEREWITH INCLIJ,DING POLICE DETAILS AND OTIIER REMEDIAL MEASURES DEEMED
NECESSARY BY THE MUNICIPALITY.
TIIE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGR.EE JOINTLY AND SEYERALLY TO DEFEND,
INDEMNITY, AND HOLD IIARMLESS TIIE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES TROM
AIYY AND ALL LIABILITY, CAUSES OR ACTION, COSTS, AND E)PENSES RESULTING T'ROM OR ARISING OUT
OF ANY INJIJRY, DEATH, LOSS, OR DAMAGf, TO ANY PERSON OR PROPERTY DURING TIIE WORK
CONDUCTED UNDER THIS PERMIT.
APPLICAIYT SIGNA
DATE r la la4lt
EXCAVATOR SIGNATI]RE (IF DIITERENT)
DATE
OWNER'S SIGNATURE (IF DIITERENT)
DATE:
oc'ilr'CERTIFICATE OF LIABILITY INSURANCE
COVERAGES CERTIFICATE NUMBER:REVISION NUMBER
12124023
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THISCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW. THIS CERTIFICATE OF INSURANCE OOES NOT CONSTTTUTE A CONTRACT BETWEEN THE ISSUING TNSURER(S), AUTHORTZEDREPRESENTATIVE OR PROOUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: lf the certlficats
If SUBROGATION IS WAIVED,
thls certlflcate does not confor
holder is an ADDITIONAL INSURED,
subiect to the terms and conditions
rights to the certlflcate holder in lieu
the pollcy(les) must have AODITIO
of th€ pollcy, certain policies may
of such endorsemenl(s).
NAL INSURED provisions or be endorsed.
require an endo.sement. A statemenl on
PROOUCER
HART INSURANCE AGENCY. INC
243 I\,IAIN STREET
PO BOX 700
BUZZARDS BAY. t\.4A 02s320700
Erica H. O'Connor
eoconnor@hartinsurancea com
INSUR ER(S) AFFOROTNG COVERAGE
lrisuRED Ace Excavation lnc. Edward Tallent
588 Bourne Road
Plymouth, MA 02360
INSURERB NATIONAL GRANGE MUTUAL INS CO 14788
INSURER E
ITISURER F
HAVE
THts Ts CoERTI HAT TT EH lcPOL E oS SNU ENC STLI BEDE HOW BE EEN SUEDs THTO NsU DE ENAMD BOVE Ro THE COL ooERINDCADTEo'n tN TAN ERN,ITTHSDNG o Nco oDTI oN AN NCo CTTRA OTHOR E DO UMcENT RETH CTSPE TO H C THH SMEBSUSoEDHTEUNSRANFORDBYEDETHESDCREDBERHENSSUBTTECoLLHTTEER[,1S,cEX usrL No ANDs DcoNtTt ON OFS UCs POLHIC LIMITS HSOWN EEB REN UD DCE B CD MLAIS
IYPE OF INSURANCE
ELACH OCCURRENCE 2,000,000s
ES 500,000$
MED ExP (Any one pe6on)10,000$
PERSONAL& ADV INJURY 2,000,000$
GENERAL AGGREGATE 4,000,000s
PRODUCTS COMP/OP AGG 4,000,000S
COII ERCIAL GENERAL LIABILrIY
crarus,vroe / occun
GEN'L AGGREGATE LIMIT APPLIES PER
/ porcv il"o; Loc
OTHER:
MPJ3478T 11119t2423 '11 t'19t2024
S
ELIMT $
aOOTLY INJURY (Pqp6.sm)5
BODILY INJURY (Per accident)$
S
5
EACHOCCURRENCE $
AGGREGATE $
OED RETENTION $
AUTOMOBILE LIABITITY
SCHEOULED. AUTOS
NON-OWNED
AUTOS ONLY
UfBRELLAUAB
EXCESS LIAB
OCCUR
CLAIMS.MADE
OWNEOAUIOS ONLY
HIRED
AUTOSONLY
$
1,000,000s
E L D SEASE EA EMP 1,000,000$
B WORKERSCO PENSATION
AND E PLOYERS'LhAIITY
ANYPROPRIETOF'PARTNEFVEXECUITVE
OFFICEFVMEMBEREXCTUDEO?N
DESCRIPTION
wcJ3383T 10t14t2023
E L, OISE4SE. POLICY LIMIT
E L EACH ACC]DENT
STATUTE$nanoza {
1,000,000$
oESCRIPTIOT{ oF oPERAnoNs , Loc^no s / VEHICIES (AcoRD 101 , Additional R.m.rts sch€.lul., may bo .tt ch.d it mor. .pace i. requ n d)
CERTIFICATE HOLDER CANCELLATION
Fax #: (508) 398-0836
TOWN OF YARMOUTH
1,146 MAIN STREET
South Yarmouth, lrA 02664
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATIOT'I DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
O 1988-2015 ACORD CORPORATION. Att rights reserved
The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03)
II|SURERA MAIN STREET AMERICA ASSURANCE CO
INSURER D :
REQUIREI\,IENT,
CERTIFICATE PERTA N.POLICtES
I
I
Il",o I
AUTHORIZEO REPRESENIATME