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HomeMy WebLinkAboutBLDT-24-130 "Tt 'YR ���)1V V OF .�R\IOt I H 3 e o=� BUILDING C, DEP.1Rr�tEN r Permit Number Az-D71Y-/3O - �� 1146 Route 28, South Yarmouth. :‘1 Is 11266.I �� ''' Date Issued 4 ..... ) ,y� 5118-398-223I ext. 261 Fax 5118-398-11836 Expiration Date l`t�0 o rive rS e ease f511'.. TRENCH PERMIT Pursuant to C.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended) 5( THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant F 1 i 1`1/4s Aro'trs Phone Cell Street Address .2 3 /�`h 1 er pn`5e /'a�Lg S 3 jji t �a 3 J kern MA '; ZIP ` 1fOlanlerof Excasator(ipifferent from applicant) Phone Cell Street Address Citylrown MA 1 ZIP i 1 Name of Owned. )of Property Phone Cell . arL�n —COd a37 �47a9 Street Address 70 jJe h S City/Town ii MA ' ZIP �, r r� pd — j oa 675 Other Contact _Permit Fee Received No( 1 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 i -• .1 be laid in proposed trench(eg:pipes/cable lines etc..)Please use reverse side if additional space is ... , •I r• S hhow, Leszk) 1 RE. c. ` _. _. pus 1 — ._--OEp (2TMEN .i gV1Lp1N _________— --- Essi,------- Insurance Certificate#: wCC."Soe soap 704 49.0a3 Name and Contact Information of Insurer: 1 f}SSOc t'4 Pa' /=" 6 .S n&eV,' r . Polio} Expiration Date: {aT3TaT --. ---._ Dig Safe#: o D 4 2 " 5 1 Name of Competent Person(as defined by 520 C'MR'7.02): -- — `1"�ty 1=11tIS l of 2 Massachusetts Hoisting License# H C , 6,9 e6 3 la 130 i 9.0 License Grade: it 2' g aci."` &el.vy► _ Expiration Dom: 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. c. SM, 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 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 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 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. 7LICANT SI TURE i r DATE ."'-- 9' .. EXCAVATOR SIGNATURE(IF DIFFERENT) RENT) DATE O NER'S SIGNA RE (�DIFFER.ENT) .. wi/%I _ - wax, _ DATE: 5 /Q2//A1)2 — .- e Etir cionwimims --Oe sioe awe A A 2 of 2 I 1 L. Commonwealth of Massachusetts titDivision of Occupational Licensure i-a; rigltng er tp HE-028(73 Aires: 1213012024 LAURENCE 5 ELU '+ to 8NORTTHsr DENNIS POR AMA 1 :=:;: t t h- , Q. o Commissional- daJcpa g. at. • Hosting Engineer Restricted to: HE-2A-Excavators DIG SAFE Call Center: (888)344-7233 In case of accident call: (80 )820-1444 Contact OPS!: (617)727-3200 or visit www.mass.govldpllopsi • a.. dx I i r 4 A CERTIFICATE OF LIABILITY INSURANCE DATE (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 PHONE RogersGray SBC I FAX 410 University Ave .vac.NV.Ext): 781-208-8400 I(A/C,No): Westwood MA 02090 ADDRESS: ra rgsbc@ ro9 ers .com 9 Y INSURER(S)AFFORDING COVERAGE NAIL# Licensg#:PC-514082 INSURER A:West American Insurance Co 44393 INSURED REID&LA-01 INSURER B:Arbella Protection Insurance C 41360 EIIIS Brothers Construction Co. INSURER C:Associated Employers Insurance 11104 dba Reid& Laurence Ellis 23 Enterprise Rd P.O. Box 59 INSURERD: 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 ADbL SUBR POLICY EFF f POLICY EXP LTR TYPE OF INSURANCE INSD 1 WVD POLICY NUMBER (MM/DDIYYYY) (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY BKW58371201 3/1/2023 3/1/2024 EACH OCCURRENCE $1,000,000 CLAIMS MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $100,000 MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $2,000,000 _ X POLICY L. J JJPREa- LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ B AUTOMOBILE LIABILITY 1020002607 6/9/2023 6/9/2024 Ea aBINEDtSINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $250,000 OWNED y SCHEDULED BODILY INJURY(Per AUTOS ONLY AUTOS accident) $500,000 Xy HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY Jr AUTOS ONLY accident) $100,000 $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED ', RETENTION$ $ C WORKERS COMPENSATION WCC-500-5000706-2023A 12/3/2023 12/3/2024 X AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $100,000 OFFICER/MEMBEREXCLUDED? 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 . I 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 AU EDREPRESENTATIVE South Yarmouth, MA 02664 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD