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HomeMy WebLinkAboutBLDT-25-4 v1'Y`�R CONVN OF 1'.1R\R)t'"III Yi' o� BUILDING DEPART�(FN F Permit Number %3zoj-25. _ , ' , 'c' 1146 Route 28. South \ armouth. NIA112664 '� rr: ."3) 508-398-2231 ext. 261 Fax 5418-398-0836 Date Issued 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 e.11;{ 6 46 CO Phone C,ei Street Address v 1 /�' C (f,', 3 7 3 6eram' J CityfTown MA ZIP ' Gaili7 S Na of Excavator i d Brent from applicant) Phone Cell t pp e Street Address City/Town MA I ZIP I Name of Ownerls)of Property /lze ,/ ,/Oi Phone Cell Street Address 7 SCE iM ..S' ,�,q,,..+f. ,,�G�3 OS ���`/ City/Town MA f ZIP a f€ v ire i7i _ j C 26.13 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(or is intended)to be laid in proposed trench(eg; pipes/cable lines etc..)Please use reverse side if additional space is needed. l kt(4-- 5-924 ' REC ElyE t,N I _ r BUILDING DEPAR i,, -_ i 8Y 1 Insurance Certificate#: w cc SG c So 0 GG __` Name and Contact Information of Insurer: = _C•1‘444 i Ei-,0090-+ ..____ Policy Expiration Date. 1 A3 ) S / Dig Safe#: a O a H S Name of Competent Person tas defined b 520 C'MR 7.02): L4rto Eli I of 2 " I VIA! Massachusetts Hoisting License M E GI.6-6 73 ) 60 License Grade: i+1z. -9-� i. C ry—j Expiration 13 es 2 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. S2A, 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 BIT 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. APPLICANT SIGNATURE 1 DATE i r � — EXCAVATOR SIGNATURE(IF D RENT) DATE OWNER'S SIGNATURE(IF DIFFERENT) /a -.r -_DATE: / //7/ Y f FarS. owntor—Denis In I AMC"p la1i ... .Appocsom Fir f mourn. 'At TNflI ti Daft . 1 COMMICAS 1*AirStOiAL 1 2 of 1 �� ® DATE(MM/DDNYYY) CERTIFICATE OF LIABILITY INSURANCE 6m2023 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 NAMRogersGray,A Baldwin Risk Partner PHONE RogersGray-SBC FAX 410 University Ave (A/C.No,Ent):781-208-8400 (Arc,No): Westwood MA 02090 ADDRESS: RGSBC@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC S License#:PC-514062 INSURER A:Associated Employers Insurance 11104 INSURED REID&LA-01 INSURER B:West American Insurance Co 44393 Reid&Laurence Ellis dba Ellis Brothers Construction 23 Enterprise Rd,P.O.Box 59 INSURER C:Arbella Protection 41360 Yarmouthport MA 02675 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1331793718 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 ADDLI INVDR POLICY NUMBER MPOA/UDD/YYYY) (PPA�DY EXP /YYYYY) LTRSTYPE OF INSURANCE INSD I UEI - LIMITS B X COMMERCIAL GENERAL UABIUTY BKW58371201 3!1/2023 3/1/2024 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADE E Xi OCCUR I 1 ; PREMISES(Ea occurrence) $100,000 MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE UNIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY JERC0.T LOG 1 PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ C AUTOMOBILE LIABILITY 1020002607 6/9/2023 6/9/2024 COMBI(EaNEDnt)SINGLE LIMIT $ accide ANY AUTO BODILY INJURY(Per person) $250,000 ovvNED AUTOS ONLY X AUTOSU� BODILY INJURY(Per a GcideM) $500,000 x HIREDOSY Ren DAMAGE 100,000 A ONLYXAUUT ONLY (Per accident) $ UMBRELLA LAB — OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DEL) RETENTION$ $ A WORKERS COMPENSATION WCC-500-5000706-2022A 12/3/2022 12/3/2023 X STATUTE OTH- ER AND EMPLOYERS'LIABILITY Y r N ANYPROPRIETOR/PARTNER/EXECUTIVE !NIA E.L.EACH ACCIDENT $100,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) EL.DISEASE-EA EMPLOYEE $100.000 If yyes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $500,000 I 1 DESCRIPTION OF OPERATIONS I LOCATIONS I 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 ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth 1 146 Route 28 AU;[ ED REPRESENTATIVE South Yarmouth MA 02664 .._ , a' ©1988-2015 ACORD CORPORATION. All rights reserved ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Division of Occupational Licensure HE-028673 z Spires:12130/2024 LAURENCE F ELLIS JR F 8 NORTH ST' DENNIS POR't MA 02839 Commissioner (AA Hoisting Engineer Restricted to: HE-2A-Excavators DIG SAFE Call Center:(888)344-7233 In case of accident call: (508)820-1444 Contact OPSI:(617)727-3200 or visit www.mass.gov/dpllopsi A 014J 7 auk L ''C 546 q// °