HomeMy WebLinkAboutBLDT-25-48 application •
o TOWN OF YARMOUTH Permit # 6 Lb1-_ ,,2 R
? BUILDING DEPARTMENT
re 1146 Route 28, South Yarmouth, MA 02664 Date Issued
`,G- 'r' 508-398-2231 ext. 1261 Fax 508-398-0836
A t i
Fee $50.00 ( -)0Y7
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended) i
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATIONPR 18 2025
Name of Applicant C ..Naf) R c,,,),. ,,IXnPhone Cell
Street Address 77U( o(/LY 25V
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City/Town MA ZIP Email
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Name of Excavator(if d' fere I.,from applicant) Phone Cell
St'l G. \--Nc--`, J L ���1�Q.. C
reet Address
8 0, P )c) ► n 9 u .2-2ti s(6)
City/Town MA ZIP Email
Name of Owner(s of Property Phone Cell
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Street Address �Dot1b VIoov�'�
City/Town MA ZIP Email
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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.
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Insurance Certificate#: wz.t.. 3 g AleA5' �3 0
Name and Contact Information of Insurer:
N e - - cs_ gif - a CV 9
Policy Expiration Date: 1 O" 17 — ,9 0.2_s----"
Dig Safe#: OAS. )
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Name of Competent Person(as defined by 520 CMR 7.02):
Massachusetts Hoisting License#
License Grade: 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.82A,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 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
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EXCAVATOR SIGNATURE ( F DIFFERENT)DATE � 1
DATE
OWNER'S SIGNATURE (IF DIFFERENT)
DATE:
For City/Town use--Do not write in this section
PERMIT APPROVED BY $ Application Fee
PERMITTING AUTHORITY Date
CONDITIONS OF APPROVAL
Commonwealth of Massachusetts
Division of Occupational Licensure
_ � a
H `g E� eer t
HE-201182 Ftcpires: 10/19/2024
CHAD A HA1 (AWAY
15 VICTORY N F R
° SOUTH YARMOUTH MA 02664 4
•
Licensee Details
Demographic Information
Full Name Chad A Hathaway
wner Name:
License Address Information
'City: West Yarmouth
State: MA
Zipcode: 02673
'Country: _...__ United States
License Information
License No: HE-201182 License Type: Hoisting Engineer
Profession: Engineering Licenses Date of Last Renewal: 10/17/2024
.Issue Date: 8/5/2021 Expiration Date: 10/19/2026
License Status: Active Today's Date: 4/18/2025
Secondary License Type:
Doing Business As: Hathaway Septic Service LLC
'Status Change Reason: License Issuance
Prerequisite Information
;Licensee: Hathaway,Chad A
Relationship: Attribute Of
License No: HE-201182
1
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