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HomeMy WebLinkAboutBLDTR-23-000463 (Li lc. 7 id-e/a-d .R TOWN OF YARNIOUTH o BUILDING DEPARTMENT Permit Number 6z„ rTC�- p( C' 1146 Route 28,South Yarmouth, '-1a 02664 \MrTA F .( 508-398-2231 ext. 1261 Fax 508-398-0836 Date Issued od©Wal Expiration Date c, 15 LI ti $50.00 TRENCH PERMIT RECEIVED Pursuant to G.L. c. 82A §I and 520 CMR 7.00 et seq.(as anted ) JUL 27 2022 THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDF.RATTON Name of.applicant f2 (3 fxCAUOktl)n tau Phoe Cell By : TENT Street Address 3 l Ro c, l3o sV2 "411 0(05 3 - - City/Town MA ZIP Sando;ch 07.5b3 Nacre of Excavator(if different from applicant) Phone CeU Street address City/Town MA ZIP Name of Owneris,of Property j Phone Cell Street Address (I Scholl AvL City/Town MA ' ZIP '(acmoul1^. Other Contact Permit Fee Received No( ► Yes( Description,location and purpose of proposed trench: Please describe the exact location of the proposed trench and its purpose(include a description of what is for is intended)to be laid in proposed trench(ea;pipesksble lines etc„)Please use reverse:side if additional space is needed. nS11A1IC1,+1G/1 0(nrk) di (� SY►N lnsursnee Certificate*: S 2 3 g 2 8 1 Name sod Contact in(nr T atirn of Insurer SSLItckkw Policy Frpirsti 141 Dote: 5 t 2$ Di4 Sate 1 70Z22g1L656 Name of Competent Person u defined by 510 C%IR 742): _cobul' GO 1oft Maseacfiusetta Hoisting Licence I HE- Oy a 1 Q • Licence Grader Z A Expiration Date: 21 I}[24 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 FAMILIAR WITH,ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS, G.L a I2A, S2r CMR 7.011 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 THE 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 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 CONDITIONS OF THUS 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 MEASURE 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 our OF ANY INJURY, DEATH, LASS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT. APPLICANT SIGNATURE DATE EXCAV TOR SIGNATURE(IF DIFFERENT) tair DATE '2-1- ZZ, OWN R'S SIGNATURE i IF DIFFERENT) �._ ___.___._ DATE: Far 4. ea-DO ese easel*di i he 2of2