HomeMy WebLinkAboutApplication - 190 MILL ROAD 8/26/2010 08/24/2010 14:07 FAX U003
TOWN Or NORTH ANDOVE,R Permit Number
NORTH ANDOVER,MASSACHUSETTS 01845
®era, Date ,Issued
Expiration Late
T A h! •
J cki ' Lam — Pennit Applie v i
Pursuant to G.L. e. 82A §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR.TO CONSIDERATION
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Name otA,pplleant Phone Coll
Street Addnss C irrown MA ZIP
Nome otFxcavator(if different tt,om applicant) � Phone Cell
Street,address
City/Town ] MA ZIP
Name of Owner(s)of IPrope ty I hotto �Cell
:1XIN III(eet,hddress o C _.
Clt, owti 14IA�ZIP
4tltet^Contact Permit Fee Received hlo Yes
Oeserlptlon,location and purpose of proposed trench:
Please describe the exact location of the proposed trenclt and its purpose(include a description of what is(or 15 intended)to
be laid in proposed trench(eg;pipWcabla lines etc..)Please use reverse side If additional space Is n*eded,
Insurance Certificate ri<:
08/24/2010 14:07° FAX 11004
Nerve and Contact(Information of Imurer:
Po"" Ex radon Date; f"
Dig Safe M � � .� �042)�aT Cana teDDt Person(as c ei3ned bX.520
a,
Maz:Iacituaetta Hoisting License#
License Grede: ` ... "` Ex imtiou Date:
BY SIGNING THIS VOD1 M, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE
AND CERTIFY THAT THEY ARE FAMILIAR. WITH, Ott, BEFORE COMMENCEMENT OF THE
WOW WILL BECOME FAMILIAR WITH, ALL LAWS AND REGULATIONS APPLICABLE TO
WORK PROPOSED, INCLUDING OSHA REGULATIONS,G.L, e, 92A1520 CMR 1.00 et seq.,AND ANY
APPLICABLE MUNICIPAL ORDINANCES,BY-LAWS AND +t�(JLA`I`H)NS ANA)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 UNDEIISIONEID OWNER AUTHORIZES APPLICANT TO APPLY FOR THE PETtMIT 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 T!-I.E PROPERTY TO MONITOR AND INSPECT TIRE WORD
FOR CONFORMMY WITH THE CONDITIONS ATTACIII,JD HERETO AND THE LAWS AND
REGULATIONS OOVERING SUCH WORK£.
THE UNDERSIGNED APPLICANT,OWNER AND IZXCAVATOR AGREE JOINTLY AND SEVERALLY
TO REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES ANCU D By
THE MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTEID
Y 'I HEti;IrUNDEki,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'
INCLEJIDING 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 Olt ARISING OUT OF ANY INJURY, DEAT 1, LOSS, OR DAMAGE TO ANY
PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT,
„ APPLICANT SIGMA VRE
ATE
' ICAV.ATOR�IGNA"IIJ c.(IF, 111 '11ERENT)
(DATE
OWNER'S' I NATI7R (111 I.DIFFE-RENT)
DAT
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