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. TOWN OF YAR.MOUTI4
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4i''''-' '' l Bt.TILD ENG DUARIMEN t Permit Number ,,.6a,vz ,23. _
( _A 1146 Route 2S,South Yarmouth,MA 02664
508-398-223 1 ext. 1261 Fax 508-.398-08.36 Date Issued
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RECEIVED
TRENCH PERMIT 1--------------
Pursuant to G.L.e. 82A §1 and 520 CMR 7.1 t et scq.(a amended)
JUL 01 2022
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION I
.r DRS-ART ENT
Name ot Applicnki 5-6thz ci•porbe. ) Inc, Plisme _ Cell
507-cia3loOd,
Street Address 14(91 \OCtittkodlYLS+ i I
Cityffonn MA ZIP
0 6,364 t,
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['ism of Excavator(if different from applicant) Mae Cell
Street Address •
City/Town MA ZIP
Name of Owneri 5)of Property Pbone Cell
Street Address ,\)-eir,S0 0 rck cAti-cv3k)
City/Town MA ZIP
Other Contact I Permit Fee Received *( Yea( 1
Description,lodoe 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(eg,;:lealcabla lines etc-1 ate.use mem ride If add tonal space la needed.
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Insurance Certificate Ph .....e_e_. . i
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Name and Contact Information of litturer:
'--\-- ,(_::) ,:,;1:s-7-v• .I\c_\.t.irtc.),, -781-5(oq-c. ! au
. Fi2119...E;p'iration Date: ....,M) —
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'64 41 au z),(1„atiAti 0001 aodar:Ak,Notilti apaDabiLmo-t
1 :4 torte of Competelii Perla*f as defined 5.20(MR 7421:
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licente,,,...f...,.....g.,::r Gm bee .,.5:4°' ..._-,_.T.>_a,�...._....�..T..._..,_- !.Ty BI'c P4d it Di'i$•$ ( ) 6 )
BY SIGNING Tins FORM, THE APPLICANT, OWNER,AND EXCAVATOR ALL ACILNOWLEDGE AND CERTIFY
TEAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF THE WORK, WILL BECOME?AM: JAN
WILT,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS
G.L. e. S2A, 520 CMR 7.01 et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND
REGLI ATLONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR
SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FO r
BELOW.
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND 7'1
EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER. AND ALSO, FOR THE
DURATION OP 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 INCURRED BY THE
MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITONS 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 TI
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 THIS PERMIT.
ANT GNATURE
ATE
CAVATOR GNA RE(IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
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'Town of Yarrnoitth )AT}'
I}oria rtment of Pubh W(,rks PI V EFW1-1
ROAD OPENING PE „
RMIT -0-4-Aapits
Pursuant to the Town of Yarmouth requirements and applicable provisions of Massachusetts Lionel al
Laws, the undersigned respectfully requests that your written consent be given to excavate and/or tound
under the ground in the following Town/public/private way(s) for the following purposes:
LOCATION: Li5ek-i ieLe0Sork.5: PUJOLCk#4:
PURPOSE: Ilf\ toalA.ti:Vsir1/4..
Proposed depth of cut: feet (NOTE:if 3' or deeper cut is proposed,then you‘ may also
to apply for a Trench Permit from the Yarmouth Building Department-see more below.)
The undersigned agrees to conform to all applicable federal, state,and local laws,by-laws, regulations
(e.g.,OSHA),and guidelines, and to abide by all stipulations of and attachments to the Permit. In
addition.,the undersigned agrees by the acceptance of this Permit to: be responsible for all acts in
connection with this Permit;have appropriate insurance coverage for any injuries to persons or
property; indemnify the Town of Yarmouth for any of its acts in connection with this Permit; and, be
responsible for trench excavation and maintenance during the period of construction as well as trench
repairs caused by settlement and/or poor construction for a period of one year from the date of project
completion.
CONTRACTOR: izo.
Ine. PHONE: )C 3(5)0d.;1 24r „
ADDRESS: lt 1 _CONTACT:I LetL!iQ_I
,
.C1/41WWY0 PAA 0 X3q‘11 SIGNA
PAVEMENT CUTS.ALLOWED QtEse— NO INFRARED REQRED ES NO )
SPECIAL CONDMONS/A1-1 ACHMENTS:
• 1140(al IR 4 N C rtr *>c.)1.CAJOr‘ iXt
Nt -tnkc nr LA" ‘ Amdru
• Massachusetts State Law(MGL c.82A s.1 and 520 CMR 7,00 et seq)requires that an excavator
obtain a"Trench Permit"from the Town of Yarmouth prior to digging a trench,on public or
private land or within public or private ways. A"trench"is defined in the regulations as"An
excavation,which is narrow in relation to its length,made below the surface of the ground in
excess of 3 feet and the depth of which is,in general, greater than the width,but the width of the
trench,as measured at the bottom,is no greater than 15 feet." A trench permit application can
be obtained at the Building Department located at the Yarmouth Town Offices at 1146 Route 28
in South Yarmouth.
• All materials and construction methods shall meet Massachusetts Highway Department's
Standard Specifications,as amended herein.
• Permittee shall call DIGSAFE and the Yarmouth Water Division(508 771-79'2 I)at least 72
hours prior to initiating any work.
• Only one halt of the road may be closed at any one time,at least one navel lane shall remain
open to traffic flow,and adequate police direction @aid by Permittee)shall be provided.
Continued next page.
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CERTIFICATE, F a 5/21tt'12
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,TitIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED HY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT SET WEEN THE ISSUING INSURFR(S),Ammonia:)
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(tes)must have ADDITIONAL INSURED provisions or he 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 ri!hts to the certificate holder In lieu of such endorsement(s).
PRODUCER i NOAZt€ACT Lindsay Raffael
De3anctls Insurance Agency,Inc. i laic,PHONE,e.I{:(781)569 0120 LiAic..."�I:................___
100 Unicorn Park Drive Ilraffael rndesanctis)ns.com
Woburn,MA 01801 iliss: _..____......_..._._.
I MSIMERISI AFFORDINGCOVERAGE ._..._. NAIC u
INSURE A:The Travelers Indemnity Company 25658
INSURED INSURER a•The Charter Oak Fire Insurance Comypan 25615
Bay State Piping Co,,Inc. ..Ifl5UR Rc:North River Insurance Company. 21105 _____
467 Wareham Street INSURER D;The Travelers Indemnity Company of Connecticut 25682
Middleboro,MA 02346 IN RER E:The Travelers Indemnity Company of America 25666_______....._....
INSURER!:Nautilus Insurance Company 17370
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:„.„, . _
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN 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.
SUBR ...��.� P UCY EFF POLICY EXP
Pi .TYPE OF INSURANCE A 1SD barb_ POLICY NUMBER jy{yd'PYYYYI IMWODiYYYYI Lars
1,000 000
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S_„_,.,,„„,.�_,,.„.....,._.0
OAMAGE TO RENTED _____....._......._300,000
Cr,AIMs+uDe �OCCUR DTC03t?9030481ND22 .i11/2022 51112023 PNEMISkS tEa«currencel $
X Limited Pollution MEO exP iAry one person) s 15,000
)( XCU PERSONALS AOV INJURY S 1,000,000
_SCE,_N TE L AGGRE A UNIT APPLIES PER' GENERAL AGGREGATE J_-�...__ 2,000,000
2,000,000
_ POLICY jEL L� PROfX1CTS-CCAAPR�P AG(i t-}....._.__......
OTHER:.. '. } .
_.._.._.._. .._......._.._ —__—...__._-,---
COMB�IINEDSINCTI_E.BET : 1,000,000
B AUTOMOBILE LIABILITY O H �__.................
X 1 ANY AuraI l 8109M4538962226G 5/1/2022 5/1/2023 BODILY INJURYso IPer pnnl $
I VA AUTOS
ONLY �^AUTOSULED BODILY INJURY{Per acaaenf S
,.X ONLY X''AUTOS ONLY PROAMAGE
nti6.cIde ..
S
• C UMBRELLA W a X OCCUR t B4O00 000
+occualr _
X EXCEssLIAe CLAIMS-MADE 5821108453 5/1/2022 5/1/2023 AcoR GATE 8,000,000,
CEO X RETENTIONS 0 �_..__.. n— Q t S
..D 'woexses COMPENSATION i „ X ia{n�R EF2'
AND EMPLOYERS'LIABILITYSTAI AC t
rlN�I U84K2974SA222tIG 5/1t2022 ( 5/1/2023 t.L.EACHACCIDENT s 1,000,000
ANY PROPRIETOR RARTNETt/EI(ECUTIVE E N NIA "'—�
p�fICE�R�/M£M EXCL.0 DEO/ 1,OOQ000
{1lAnuatory M _EL.DISEASE. EMPLOYEE S
tT yes,ascritw caber _ EL.DISEASE•POLICY UYIr S 1,000,000
CESCRIPTIONOFOPERATIONSbelcw __............___ --^----
E Equipment Floater 1QT6607N943897TIA22 511/2022 511l2023 Deduct 1,000
F Pollution/Profess CPP203025411 10/712021 ! 1 01712 0 2 2 Occur/Aggregate 2,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES LACORD 161,Addttlonet Remra•ks Schedule,may be attaciwd 11 more space is requited{
PROJECT:Various Trench and Street Opening Permits
GER_JEICP,1 E HOLDER _ LANGt Ll A I iCll!!._._...._ __ ._.__.._..._._..____. _. .....
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 AUTHORIZED REPRESENTATIVE
JJI L6
1 e 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103)
The ACORD name and logo are registered marks of ACORD
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