HomeMy WebLinkAboutBLDTR-23-00254 ird_ ie„d 7- i CI Z-2_
TOWN OF YARMOUTH
BUILDING DEPARTMENT Penult Number --
6( ' .9 1146 Route 28,South( Yarmouth, NIA 0266,1
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508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued a g
Expiration Date 61-#
$50,00.,
i( t- CEiVED
TRENCH PERMIT i---__............
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended) , JUL 14 2022
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION ' I-----
BUILDING ' R IMENT
t by
Nouse a:Applicant i-(1.,.,,,\ C cnc,c-v-;t-- Phone Cell
cc )`-:(s--:, -3---'. C., ,r5o). -77-5-as35
Street Address
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City/Town MA ZIP
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Name of Excavator Of different from applicant) Phone Cell
Street Address
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Cityfrown MA ZIP
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Name of Ownerls/ut ProPertY C'f , ' Phone Cell
Street Address 5—c., ,'"-7c-,--ee--- --- e--(f----'-
City/Town MA 1 ZIP
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—Other Contact I Permit Fee Received No( ) Yes( )
Description,location and purpose of proposed trench:
Maio describe the exact location of the proposed trench and its purpose(Include a description of what is(or is intended)to
be laid In pmposed trench(eg;pipes/cable lines etc..)Please use reverse side if additional tpace is needed.
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Insurance Certifiesto itt
N*flit end Contact Information of insurer: ,;,...n f.,\. 04 VQQ:',\ 'i-:CN.,,jrL°r\(lit.
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Pi i i 19 Etpirstion Due:
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NIMS a Competent Penne as t ned by 510('MR 7.02):
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Mnanichusetts Hoisting Limnos *)--\ 0 r)
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BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF THE WORK,WILL BECOME FAMU1AR
WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORE PROPOSED.INCLUDING OSHA REGULATIONS,
G.L. e. FM, 521 CMR 7.01 et seq., AND ANY APPLICABLE MUNICWAL ORDINANCES, BY-LAWS AND
REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORE DONE UNDER THE PERMIT ISSUED FOR
SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH
IIFI,OW.
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WORE ON THE PROPERTY OF THE OWNER. AND ALSO, FOR THE
DURATION OF CONSTRUCTION, A1511101/17101 PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORKTTY WITH THE
CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH WORK.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AM)SEVERALLY TO
REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE
MUNICIPALITY IN CONNECTION MTH 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 THEREWTTIL.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 JOINTLY AND SEVERALLY TO DEFEND,
INDEMNIFY, AND HOLD HARMI Egg 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.
APPLICANT SIGNA7RE
-- DATE
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
Par C trim um—De sel"rile tali -
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