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HomeMy WebLinkAboutBLDT-24-129 c '• ,4 'YaR\ [OWN OF V AR IOL�'t FI 7 '/a I�, o=, BUILDING DEP kRTNIEN"T Permit Numb r l I/ - 'c` ( 146 Route 28. South Yarmouth. NIA 02664 � -'y Date Issued Y .,T. yti,_'Z' 508-398-2231 ext. 261 Fax 508-398-(►836 Expiration Date TRENCH PERMIT Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant F I'l:s profs Got Phone Cell Street Address ^ r n�1� rt�'Q / S- 4'00 D GJ City/Town p� L . A ZIP ,,,r,.. d� ot317� Nof Excavator different from applicant) Phone Cell Street Address City/Town MA ZIP I Name of Owner(s)of Property el_ lei/ i SC' Cell Phone Cell Street Address 0 3 g( 6 S73 L- lq 16111' h 6 a It Der IN G. y City/Town MA ZIP so 'h i -i 1 as&75 Other Cone t Permit Fee Received No_( ) Yes( 1 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 lines etc..)Please use reverse side if additional sp . . new L7964 cis.. __._----V r- u \ LAu616b02kj i 1, BUILDING DEPARTMENT BY --- (4/CC — 5o a -- S'000 7a( _ ,v20a319, Insurance Certificate#: Name and Contact Information of Insurer: yi Policy Expiration Date �j�f Dig Safe#: ad �� 3®l 4 (L c{ ,, .1 I -- Name of Competent Person(as defined by 520 CMR 7.02): a 1= I lof2 Massachusetts Hoisting Lice # .HI' - ooa (073 o�. 3o lait License Grade: H. a a-0` L I(s VI 1QIS Expiration te! _ BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT THEY ARE FAMILIAR WITH, OR, BEFORE COMMENCEMENT OF THE WORK, WILT. BECOME FAMILIAR WITH, ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED. INCLUDING OSHA REGULATIONS, G.L. c. 82A, 520 CMR 7.06 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 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 HIE 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 AM) 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 CONDUC 'ED UNDER THIS PERMIT. APPLICANT SIGNATURE Ct A Jiy i DATE 4 EXCAVATOR SIGNATURE (IF DIFFERENT) _Y._._ --- DATE OWNER'S SIGNATU (IF DIFFERENT) ' i , ,` „ D ATE: 7 3b7 1 - �..._,.,_ Fur!'� .,s 11 a rite in th set`# 2 of 2 ACC,�RU® DATE (MM/DD/YY'fY) CERTIFICATE OF LIABILITY INSURANCE (MM! 024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT RogersGray, A Baldwin Risk Partner RogersGray SBC PHONE FAX 410 University Ave _(A/CNo1Ext): 781-208-8400 (A/C, No): E-MAIL Westwood MA 02090 ADDRESS: rgsbc@rogersgray.COm INSURER(S) AFFORDING COVERAGE NAIC # License#: PC-514062 INSURER A : West American Insurance Co 44393 INSURED REID&LA-01 INSURER B : Arbella Protection Insurance C 413_60 Ellis Brothers Construction Co. INSURER C : Associated Employers Insurance 11104 dba Reid & Laurence Ellis 23 Enterprise Rd P.O. Box 59 INSURER D : Yarmouthport MA 02675 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 1359384696 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 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. INSR TYPE OF INSURANCE ADDL SUBR( POLICY NUMBER POLICY EFF ' POLICY EXP LIMITS LTR l INSD WYD (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY BKW58371201 3/1/2023 3/1/2024 EACH OCCURRENCE $ 1 ,000,000 1 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES (Ea occurrence) $ 100,000 MED EXP (Any one person) $ 15,000 PERSONAL & ADV INJURY $ 1 ,000.000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JE PRCOT LOC PRODUCTS - COMP/OP AGG $ 2,000.000 OTHER: $ B AUTOMOBILE LIABILITY 1020002607 6/9/2023 6/9/2024 , COMBINED SINGLE LIMIT $ I (Ea accident) ANY AUTO BODILY INJURY (Per person) $ 250,000 OWNED X SCHEDULED BODILY INJURY (Per accident) $ 500,000 AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ 100,000 AUTOS ONLY AUTOS ONLY I (Per accident) - UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB I CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION C WCC-500-5000706-2023A 12/3/2023 12/3/2024 X j PER �RH AND EMPLOYERS' LIABILITY Y/ N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? N / A — — (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 100,000 If yes. describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500.000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER 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. Building Dept 1146 Route 28 AUT. • : ED REPRESENTATIVE South Yarmouth. N/A 02664 4410 _ 74,4444."*"""ftimAuRtwAovo,- © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD • Commonwealth of Massachusetts III) Division of Occupational Licensure Hat ing tni er HE-028673 z , pires:12130/2024 LAURENCE EfELLUS ' . '. 8 NORTH STP ' DENNIS PORt MA 02 #'. r• Commissioner Ui Hoisting Engineer Restricted to: HE-2A-Excavators DIG SAFE Call Center:(888)341-7233 In case of accident call: (508)820-1444 Contact OPSI:(617)727-3200 or visit www.mass•govIdptiopsi I