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BLDTR-23-000334 _ si •v°Qd DD % e1r►0 le 1 k-� hi - ccpp,z -7 /is/zz -7I ,' Imo. ,0F�Y.,/;;i,,. TOWN OF .A MM(�I. `f /n�//? 1p�� i e 1 i�. - -- Number. ....61.) Pe...-z3 i,, t•{t'�.►:r�l'v{�` ��t��=t -�;�-�. ����..1.:�-1��: io;s1-,' -)d;' 11.46 f•ZootE 28, South 4 :tt'I:toot11, NIA !)".'(y64 -�. Fax 3 > r� it= ( Date tc Issue _....6.. O33.... _._....._. x1 ext. r b,. 3. . ..„./yy RECEIVED TRENCH PERMIT Pursuant to C.L. c. 82A §1 and 520 CMR 7.041 et seq.(as amen ed)IUL 14 2022 THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERAT1O UILDING DEPARTMENT Name of Applicant Phone Cell ®y _ day �a-tc �i,p)r���n� lol'1 Gdt,1 450 Street Address t �y t ca 3 �0 D lQ f C.II�Q,trirkit ..S`+` t4c. . 11 ^___ City/Town MA I ZIP _-- - \VAL,( , L\, 'rO , ba3i(40 - - Name of Excavator(if different from applicant) Phone Cell Street Address City/Town MA I ZIP Name of Owner(s)--v of Property Phone Cell Street Address rJSO O r C. �Yr itQ J� 6,1 City/Town MA I ZIP d.. Other Contact J Permit Fee Received No( ) 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(or is intended)to be laid in proposed trench(eg:pipes/cable fines etc..)Please use reverse side if additional space is needed. 11\5563VIL4LINU 4 G- -e.,1rcf._k-ittce Q 63AciculAt.,axe Ve--h a-- vkeis6U r co i S91 v�:r� 'b.b t au t 1 tcj •e.i t.c� \mith. V\45,(c tv� A-Arly,�.. 'Q Y,r\ b -1/o► c c{r e r 1�e)it.) VGA ID4/t t C�6t if q) OM (a3-t't. I.. ) \kitr 1.t) A r.. aiL02- A Insurance Certificate lf; e _ t,A- a c3 Name and Contact Information of Insure : Policy'Expiration Date: ,r Ji :a, 7 Dig Safe 0: r,�a a,60 -10 a Name of Competent Person l as defined by 520 CMR 7.02): i rAD...57 )(\ CICA..1\ __ _ ' cWnni4. &tit ' n I of 2 p vern-to + "ei ,Da D pip Al perm' Fer 3� j -- p/�.EiS3J.i('.�LiLS21C s Hoisting License 0 - F_) (: ei y i { ti•.�"-•.:: License Qrn atia!: _. Et isatiout Date: (<v 0'! . BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT THEM ARE FAMILIAR WITH,OR.BEFORE COMMENCEMENT OF THE WORK,WILL BECOME FAMILIAR WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA. REGULATIONS, G.L. c. 82A, 520 CMR 7.00 et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND REGULATIONS 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 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 TILE 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 GOVERING 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 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 JOLNTLY 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. LICANT SIGNATURE DATE 11/ R E AVATOR SI 'NATU (IF DIFFERENT) DATE OWNER'S SIGNATURE(IF DIFFERENT) DATE: For(.11a/Town -- not write in this NeCtInca IPERMIT APPROVED i<Y ���, ... .. Application °ca PI?RMY a A[.�TNQurir Dal f eo 4IIYIo OF At�uVAc• n_�.r�.:.... yy 2 of 2 i Town of Yarmouth DATE . Department of Public Works REVIEWE]] ROAD OPENING PERMIT J Pursuant to the Town of Yarmouth requirements and applicable provisions of Massachusetts General f 11 Laws, the undersigned respectfiilly requests that your written consent be given to excavate and/or tunnel under the ground in the following Town/public/private way(s) for the following purposes: ,i LOCATION: CAN) Cs+<i? . '(CutM5U4 LOT#: POLE#: id PURPOSE: ahS-�.1r:iActitink. of- Ugcikily clt lea l C Acti i-f N' urc.t- k vi Proposed depth of cut: feet (NOTE: if 3' or deeper cut is proposed,then you may also need 6►'urt$L) i. to apply for a Trench Permit from the Yarmouth Building Department-see more below.) Y U _ krcbb \KZV Ic ► .. (DA, Pm*6 W low Cto-t co/ .6%41 k) `t. l?nn,4 iot1 jaa.©Cltr � ki The undersigned agrees to conform to all applicable federal,state,and local laws,by-laws, regulations ij (e.g., OSHA),and guidelines,and to abide by all stipulations of and attachments to the Permit. In addition,the undersigned agrees by the acceptance of this Permit to: be responsible for all acts in connection with this Permit;have appropriate insurance coverage for anyinjuries topersons or j � � j ji property; indemnify the Town of Yarmouth for any of its acts in connection with this Permit;and, be j" responsible for trench excavation and maintenance during the period of construction as well as trench il repairs caused by settlement and/or poor construction for a period of one year from the date of project FM: completion. Pi CD.s6-6 P t CONTRACTOR7&� l + ,-,c, PxoNE: 0$'d+3��, a `.11 p. ADDRESS: to ,IAJCIAtIASLYIAsS CONTACT', y B i. , tit , Ili llk rkl,U1D� A,.Oa b 0 SIGNA ' '7/ f ,' / a PAVEMENT CUTS ALLOWED YES NO INFRARED REQU I'd D YES NO Iv SPECIAL CONDITIONS/ATTACHMENTS: II • ii1. • 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 li` private land or within public or private ways. A"trench"is defined in the regulations as"An i. 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 I III::.:.trench,as measured at the bottom, is no greater than 15 feet." A trench permit application can ;r. be obtained at the Building Department located at the Yarmouth Town Offices at 1146 Route 28 3 in South Yarmouth. • All materials and construction methods shall meet Massachusetts Highway Department's Standard Specifications,as amended herein. i. • Permittee shall call DIGSAFE and the Yarmouth Water Division(508- 771-7921)at least 72 hours prior to initiating any work. • Only one half of the road may be closed at any one time,at least one travel lane shall remain I, open to traffic flow,and adequate police direction(paid by Permittee)shall be provided. Continued next page. 1 of 2 rr: .-..,.-r„........ 0 f--77- 1..........,...„.:-.._,...; U.1 Z Z < CS 11---------\\ t.. i t. C.) .. ) r .."4 c" • 4 --' 4,..0- \\ C'1;;$' \ N Csd CO < -'''''' .., , , ,, , - - - 07, .-...., , ,.... _ .C,) 0 , ,, ,„„.„..., ...„ A: ev -1--- IL() 8 4..a ....- .,,,,.. - „4.. 4. N , 7 cr) ..,....„ • .., •-.„,.. 'C'.tS) \ \ II 4 4 WI Ifirs) 0 ..- '..4—......,.... .—i i 0 C . op .. .0 0 Og ill . to 1111MB g riii U j , Z Lij N Z Zip- Fa Ps 0 (.) 0 co (I) L .., v-- . 1 $ L ....._ er --... ci3 0 0 44. 0 ir---- z , - ... -, a '‘'''' 4 0. 0 ,c.) 'tsu 0 ce „....., ....,...... ,...,. - ..., ... , _.„ ....._ \ cf, fX 5 il , \ tc2, 1 \ , •,i"--- t , i 1 1 7-- 1 \ 1 1 ' — ! ,,,,,----- BAYSTKI-04 LRAFrAF,i, /Ai#7,::()Y,44.) i),T i(0,1t4rOWYPt n GERTIFIC;ATE OF LIABILITY INSURANCE f;/2/202'z, THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO Rierrs UPON THE GERTIFICA i E HOLDER,THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY nib POIJOIEE; BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURFR(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the polkyfles)must have ADDITIONAL INSURE!)pi()visions. Of be endoi kiti. If SUBROGATION IS WAIVED, subject to the terms and conditions of the poky,certain policies may rogue e an endoiseinoni, A,taiemeni.Of s this certificate does not confer rights to the certificate holder In lieu of such endorsernent(s). — _ — !;PRODUCER WarkkCT Lindsay Raffael ---- — --- ,DeSanctis Insurance Agency,Inc. PHONE tAJC,No,ex.9.,100 (781)569-0120 1 FAX < I WC,No):Unicorn Pa&Drive --: ,Woburn,MA 01801 Miss,Iraffael@desanctisins.com i INSURER(SI AFFORDING COVERAGE .!At..!.... INSURER A The Travelers Indemnity Company 25658 I INSURED INSURER Gibe Charter Oak Fire Insurance Company 25615 Bay State Piping Co.,Inc. INSURER c,North River Insurance Company 21105 467 Wareham Street yystiRE n,The Travelers Indemnity Company of Connecticut 25682 Middleboro,MA 02346 INSURER C:The Travelers Indemnity Company of America 25666 INSURER F:Nautilus Insurance Company ,1 7370 COVERAGES CERTIFICATE NUMBER: 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 DOCuMEN r VA TH RESPECT to IA/111CH 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 PAO CLAIMS. vise TYPE OF NSU IlisocLISIver --chaPtiLAYX POLICY EXP LTR, IRANCE POUCY NUMBER 1 IMM/DZIFM,YI LINTS A X COMMERCIAL GENF-RAL LIABILITY EACH RR a 1,000,000 , — 1 CLAIMS-MADE rxi OCCUR OTC03E9030481N022 5/1/2022 5/1/2023 RIANF'sirsrUENTE9 s 300,000 X Limited Pollution mEc Exp tArw 0,1eseomn ; 15,000 X XCU PERSONAL&ADV INJURY $ 1,000,000 1 GEL AGGREAIF LIMIT APFLI 2,000,000 S PER' GENERAL AGGREGATE I 2,000,000 T ooL,,cy I 1 78: i LOC PRODUCTS•COMPOOP AGO $ ,..._. OTHER, , $ B AUTO wintury COMBINED SINGLE LIMIT 1,000,000 BILE (Ea woman s X i ANY AUTO 8109M4538982228G 5/1/2022 6/1/2023 BoisiLYI T(Pc"Pe's0ni $ . ONWEO schiEouLez I AUTOS ONLY i ALTOS FIGOILY WJURY(Par*olden",$ FAIR 014..' lc_ILCV(g34A.9 OPif .AMAGE i C X• MORELLA UAW X OCCUR [ Egat? EAH OCCURRENCE $I 1 8,000,000 X EXCESS LIAR CLAIMS-MADE 5821188453 5/1/2022 5/1/2023 AGGREGATE. ; 8,000,000 DEO X RETENTION$ 0 $ D ,WORKERS COMPENSATION X PE! TE-1. lir- ,AND EMPLOYERS'LIABILITY 1 UB4K29745A2226G 5/1/2022 511/2023 1,000,000 Inyi ANY PROPRIETOR/PARTNER/EXECUTIVE ,,, E L ACH ACCJ N NT $ 521gtoilf:AyEng EXCLUDED, re N I A EL,DISEASE.EA EMPLOYEE,$ 1,000,000 Iff)CSIORTMVedPERAT.ONS beiew . E.L.ols4AsE•POLICY LAST i s 1,000,000 _ E Equipment Floater 0T6607N94389711A22 5/1/2022 5/1/2023 Deduct 1,000' F Pollution/Profess CPP203025411 1017/2021 101712022 Occur/Aggregate 2,000,000' DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES[ACORD 101,Additional Remarks Schedule,may be attached It mare settee he requited, PROJECT:Various Trench and Street Opening Permits CERTIFICATE NOLDER_ 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 — AUTHORIZED REPRESENTATIVE Lia4a#47 ACORD 25(2016/03) Cii 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD N*44, C: c--3 Q- • N c., cs. ois- -4.s.z.- z.., Q. C...' ...Qz. (I) S"' (-**; .,, c ----„, N :k--) Zi "M..... -) 4) .'-> 4 0 $, 0 C)... l'*. (4_ 1 4'6.1‘ V ,•11:.,sil. 0 c r\ , • i:►-,-C s®1s11 omiso--4: .. , .. .' IQ() 1: ut.merrl ; I okA 0a.,)ictr_., grxAci LinCitl- 5.--'1/41-COX Ilk,A OflakOr 1 UM- Town of Yarmouth I)/V1 I.', Department of Public Works REVIEW/il) -Putalor Chip (Or/c Cemelcictl 1 koven-kr U , .2 C C ROAD OPENING PERIV(IT _-_-_co k i_0_ .g;Dat:i...__ i Pursuant to the Town of Yarmouth requirements and applicable provisions of Massachusetts General 1 1 Laws, the undersigned respectfully requests that your written consent be given to excavate and/or tunnel under the ground in the following Town/public/private way(s)for the following purposes: LOCATION: 01,-,) COS , YOtitiM451A-141 1,0T#: POLE#: , PURPOSE: 1 t ' rciactlialLtet,rtadif4-ek, 1 i, Proposed depth of cut: feet (NO lib: if 3 or deeper cut is proposed,then you may also needs II to apply for a Trench Permit from the Yarmouth Building Department-see more below,),. Aiv A I, I la- ArkiZ 1.05 YLACi Ns-c-YON, PyAkilk 4/010 0.0 CiwKett to) tb eiviA.Rotii6J-0 C 44,„w ) 1 i 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 1 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. 0. i CONTRACTORT-ZA S-164 *ii. 1 . Inc PHONE: Oe'd1360- C.14,11 ADDRESS: (0 CONTACT.,Alta ..., 'Beg- • I. _ 1 - i 1 ____SIONA '`U raf6141VAINW, ..;;• , f -if , IF 1 PAVEMENT CUTS ALLOWED YES NO _. Rilla_s_i3 DRE RE U i'_4 D YES( 0 I SPECIAL CONDITIONS/ATTACHMENTS: • OW_ / ,,, L-- , n. _ A, Rsibbcr Clup !tit() (Ii-AA ' ' ' • Massachusetts State Law(MGL c.8 A 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 DIGSA1T and the Yarmouth Water Division(508-771-7921)at least 72 hours prior to initiating any work. • Only one half of the road may be closed at any one time,at least one travel lane shall remain open to traffic flow,and adequate police direction(paid by Permittee)shall be provided. Continued next page. 1 of 2