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HomeMy WebLinkAboutBLDT-25-19 t '-, ,„.Y4R TOWN OF kRNIOI'"I.FI er r`' , �o BUILDING DEP kRTsIENT Permit Number Be. 7-Q �5 .10,, ,i� )c`• 1 146 Route 23. South ti arntouth. AI 112664 ��� i �y+ Date Issued %),....1 ...yritZ' 508-398-223I ext. 261 Fax 5(t8-318-11836 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 Phone Cell ,,IGW LSL L�4G ZC flc St 9,5,' ��>v� So 5 U o-36 7 ,3So o City/Town MA ' ZIP Name of Excavator(if different from applicant) Phone Cell Street Address Citylrown MA i ZIP I Name of Owners)of Property Phone Cell treet Address OK-3 7_ 3 " 0 q �c5 ) IG t,, .�c < City/Town MA I ZIP Ya-kot®iC.;-h r 4A-r / t A I U24, 7S 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 intended)to be laid in proposed trench(eg:pipes/cable lines etc..)Please use reverse side if additional space is needed. 5tr iI { n Insurance Certificate#: _ s©O 1 Q 6 - V o_wGG Soo 00 ��ig Name and Contact Information of Insurer: 4 g oc41'e 4 ii 11, r i hs0_#--... : Policy Expiration Date: ']9)/3/ I Dig Safe#: Name of Competent Person(as defined by 524 CMR 7.02): Lk rrd Fin )5 1of2 Massachusetts Hoisting License# /�12: _6 a Ss673CVN License Grade: (1 1Z a — 9 Expiration Date! 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. BZA, 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 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 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 BOLD 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 SI ATURE DATE J. EXCAVATOR SIGNATURE(IF D RENT) DATE OWNER' S GNATURE(IF DIFFERENT) DATE: /17/ For car .tow—Din ant is rihr in WAVY AIPPRO% *% 1 4&'T e c wa or Aims"AL 2of2 •"• • . I. YY) A ®® CERTIFICATE OF LIABILITY INSURANCE DATE 025 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(les)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). PROMiCER CNNAMEACT RogersGray-SBC _ROroe'sGrr`ay.A Baldwin Risk Partner PHONE FAX 4 Un versit j Ave A/c.No.Ed):781-208-8400 (ac,No): Westwood MA 02090 ADDDDRESS: rgsbc@rogersgray_com INSURER(S)AFFORDING COVERAGE NAIC# License#:PC-514062 INSURER A:Arbella Protection Insurance C 41360 WS-IMO REID&IA-01 INSURER B:Associated Employers Insurance 11104 E::s Brothers Construction Co. -ter=Reid&Laurence Ellis INSURER C:Ohio Security Insurance Compan 24082 23 Enterprise Rd INSURER D: P.O.Box 59 INSURER E: Yarmouth port MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER:314758700 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 1 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. ILTR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP.JMMIO LIMITS INSO wvo POLICY NUMBER (MMIDD/YYYY) DIYYW) C X COMMERCIAL GENERAL LIABILITY BKS58371201 3/1/2024 3/1/2025 EACH OCCURRENCE $1,000,000 GE TO RENTED J CLAIMS-MADE X OCCUR PRREM PREMISES Es occurrence) $300,000 ' 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-r LOC_ PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY 1020002607 6/9/2024 6/9/2025 COMBINED SINGLE LIMIT $ (Ea acddentL 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 (Per accident) _ $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ _ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ B WORKERS COMPENSATION WCC-500-5000706-2024A 12/3/2024 12/3/2025 X AND EMPLOYERS'LIABILITY STATUTE ER _ IV ANYPROPRIETOR/PARTNER/EXECUTE IY/NI E.L.EACH ACCIDENT $100,000 OFFICERIMEMBEREXCLUDED? NIA (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 ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth 1146 Route 28 AU PRESENTATIVE South Yarmouth,MA 02664 cs� '""-`^�•, t.K't'ilsec Details ---- Demographic Information Fuult Name LAURENCE F ELLIS JR Owner Name License Address Information City: Dennis Port State: MA Zipcode: 02639 Country: United States License Information License No: HE-028673 License Type: Hoisting Engineer Profession: Engineering Licenses Date of Last Renewal: 1/16/2025 Issue Date: 12/30/2010 Expiration Cate: 12/6/20256 i License Status: Active Today's Date: 1/17/20252/ 0/2 Secondary l-icense Type: Doing Business As: Status Change Reason: License Renewal Prerequisite Information Licensee: ELLIS JR.LAURENCE F Relationship: Attribute Of License No HE-028673 No Available Documents c Commonwealth of Massachuse ( Division of Occupational Licensure 4Y HE-028673 pires:12130/2024 LAURENCE fr ELLIS JR. . F - 8 NORTH ST' DENNIS PORL}MA 02639 4•1" et .•:.v. l,F,L1�14 z . r Commissioner Coa i g Si&k,Ik�. • Hoisting Engineer Restricted to: HE-2A-Excavators DIG SAFE Call Center:(888)344-7233 In case of accident call: (808)820-1444 Contact OPSI:(617)727-3200 or visit www.mass.govldpilapsi