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HomeMy WebLinkAboutBLDT-25-65 applicaiton -r ._ p BUILDING DE:P.kRT11F,ti T Permit Number _6(.,)T-c 5 --cp5 ,,,iri )y 11-16 Route 28. South l at-mouth, NIA 02664 L r...�.�'� �����'� :04-398-223 i eat. _'6 t F;t� t1R-3�8 0836 Date Issued C 3 �)L �' Expiration Date 56.00 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 Ellis Brothers Const. Phone Cell 508-362-6237 Street Address 23 Enterprises Road, P. O. Box 59 cityrrow MA ZIP Ellisbrothers@comcast.net Yarmouth port 02675 Name of Excavator(if different from applicant) Phone Cell 508-400-4063 Street Address SAME City/town MA ZIP Name of Owner(s)of Property_ Phone Cell :e,:1a,Ne.,& H,1-1%11:k leg ocA6ts-TR(Z1- t,I irStri.e0t4 Street Address 1-44 4sodwand viI41 City/Town MA i ZIP vets-r Ll.Ag love LM o2643 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. RECEIVED MAY 30 2025 BUILDING DEPARTMENT By: insurance Certificate#: �� 9LI/ GG—' SeG — SQc674' G Name and Contact Information of Insurer: i_ SS o C ‘G4 e C) yam,pi cO, '/1 hail r6.e 6--e Policy Expiration Date: ! af _ ____---- Dig Safe#: aoa3 __ Name of Competent Person(as defined by 520 CMR 7.02): L a r _ Yw� 1of2 Massachusetts Hoisting License# V- li"a2"' 73 License Grade: 1f r —`.ZJ 193.-VC/V/191 Expiration Date. 12/3 0 /62cd6 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 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. APPLICANT SIGNATUREAT ka � DATE �_ �- .23 z EXCAVATOR SIGNATURE(IF DIFFERENT) DATE OWNER'S SIGNATU (IF DIFFERENT) ct' tA ` '`—. C 5/t / 2 d'-2.S Sy 7 PERNITTAIG ! roar Tr' APPOD%AL • 2of2 I,it•ilisre i)o.tail : I)entngtappie term-ma•h.n Full Name: LAURENCE F ELLIS JR Owner Name: I.ieense Aditre.Infurmatinm City: Dennis Port • State: MA Zipcode: 02639 'Country: United States • license Information ,License No: HE-028673 License Type: • Profession: Engineering Licenses yf Hoisting Engineer 9 g Date of Last Renewal: Hoisti p25 Issue Date: 12/30/2010 Expiration Cate' 12/30/2026 License Status: Active Today's Dale: 1/17/2025 Secondary license Type Doing Busiriess As: Status Charige Reason: License Renewal • Prerrquicitt'!affirmation Licensee ELLIS JR.LAURENCE F Relationship' Attribute Of g= License No HE-028673 tea_... No Available Docurrrents Commonwealth of Massachusetts AL, Division of Occupational Licensure �,aC HE-028673 ti' ' spires:12/30/2024 LAURENCE ELLIS JR • 8 NORTH STf DENNIS POR t�MA 02638 r. ti eFU'� T.LHL1���, . Commissioner ccf ocei cfitn_ • Hoisting Engineer Restricted to; HE-2A-Excavators DIG SAFE Call Center:(888)344-7233 In case of accident call: (500)820-1444 Contact OPS1:(617)727-3200 or visit www.mass.gov/dpl!ops) AC RD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YY1 r) 44,01•0.444.-- 1/29/2025 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 cert ficate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCE,I CONTACT NAME: RogersGray-SBC Rogers. tea ,A Baldwin Risk Partner PHONE FAX Unr,ret y Ave c.No.Eno:781-208-8400 (A/c,No): Westwood'ood MA 02090 ADDDDRESS: rgsbc©rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# License#:PC-514062 INSURER A:Arbella Protection Insurance C 41360 4 IBC REID&LA-01 INSURER B:Associated Employers Insurance 11104 I Efts Brothers Construction Co.i ilea 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: I 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 SUER POLICY EFF POLICY EXP LIMITSLTR INS° WVD POLICY NUMBER (MM YY/DD/YY) (MMIDDIYYYY) C X COMMERCIAL GENERAL LIABILITY BKS58371201 3/1/2024 3/1/2025 EACH OCCURRENCE $1,000,000 AGE TO RENTED CLAIMS-MADE X OCCUR PREMISES Ea 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 JECaT LOC_ PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY 1020002607 6/9/2024 6/9/2025 COMBINED SINGLE LIMIT $ (Ea arsidentL ANY AUTO BODILY INJURY(Per person) $250,000 — OWNED X SCHEDULED BODILY INJURY(Per accident) $500,000 AUTOS ONLY AUTOS X x - HIRED NON-OWNED PROPERTY DAMAGE $100,000 AUTOS ONLY AUTOS ONLY (Per accident) - UMBRELLALIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WCC-500-5000706-2024A 12/312024 12/3/2025 X AND EMPLOYERS'LIABILITY STATUTE ER ., ANYPROPRIETOR/PARTNER/EXECUTIVE +Y/Ni E.L.EACH ACCIDENT $100,000 OFFICER/MEMBEREXCLUDED? I 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 - 1 - 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 A South Yarmouth,MA 02664 DT EDRE�PRESENTATIVE �, J