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Home My WebLink AboutApplication - 351 WILLOW STREET 7/2/2013 TOWN OF'NORTH ANDOVER Perinit Number N0R'l"H ANC OVEII, 019,15 %44 Date Issued ! 3 17�y,g4.@0 nm��O 0 Expiration Date 'r?r.+Q nb,nT[p Ia+s�h.<j '�4'yk(-yU J"t' 4wm'nrua Fee l ' W T Jackie's Law — Permit Applicatioll iOW (if ff�'P i;..i.kfl d € 1lf.l Pursuant to C.L. e. 82A §1 and 520 C11i R 7,00 et seq.(as amended) THOS PERMPT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Marne of Applicant 7',F,C, Cell g8`"'prte Street Address ' Cr r30> �Ga j 9 "4 —Cg48 9°7p-Wh Cityfl'mwn MA "1.:141 i D0nJ0C-,j , M 1 0192- 3 Narne of Excavator(if different from applicant) Phone, Cell Street Address CitylTown lA ztP Name of Owner(s)of Property Phone Cell � s f , �o � 'icStreet rls 5 �,it /°J�04Vi1 NIA ZIP iU P N D6 0 F,R 0184-5- Other Contact Permit Fee Received Ng Yes ) Description,location and purpose of proposed trench: w Please describe the exact location of the proposed trench and its purpose(inclu.de 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. TF k 'T Fes R /v5-W Z4 d'-1 4, Jul 6p,6 0/ 1 t4 N YES'. Insurance Certificate#._....�... —_., ___.� _.. ._...�..,.�.....�..��. �,_..•.�.,_w._._....._...J Name and Contact Information of Insurer: 166Y 9'78 . Policy Expiration Bate: Dig Safe#: ! Name of Competent Person(as defined by 520 CNIR 7.02): JOB 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 WORIti, WILL BECOME FAMILL4R WITH, ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED, INCLUDING OSIIA RLGULr1TIONS, 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 PLRNIIT ISSUED FOR SUCH WORK WILL: CONIPLY'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 DURA'T'ION OF CONSTRCJC:TION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONITOR AN]) Y.NSPEC'I THE WORK FOR CONFORMITY WITH TIII CONDITIONS AT"I:ACHED HERETO AND THE LAWS AND REGULATIONS GOVERING SUCH WORK. THE UNDERSIGNED APPLICANT,ORVNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO REIMBURSE THE MUNICIPALITY POI2 ANY AND ALL COSTS AND 1,XPENSES INCURRED BY THE MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED "THEREUNDER,INCLUDING BUT NOT LTNIITLD'I'O ENFORCING THE.FiEQUIRI MEN'I-S OF STATE LAW AND CONDITIONS OF THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES TAKEN BY THE-MUNICIPALITY TO PROTECT THE PUBLIC 'SV.HERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL M&ASCIRES DEEMED NECESSARY BY THE MUNICIPALITY. THE UNDERSIGNED APPLIC.'ANT, OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,INDEMNIFY,AND HOLD HARMLESS THE INIUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM ANY AND ALL LIABILITY,CAUSES OR ACTION,C:OS'1'S,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 a " r"5. DATE z //-3 AVATOR SIGNATURE (IF DIFFERENT) DATE OWNER'S SIGNATURE(IF DIFFERENT) DATE: 2 1I• a ,t na JTOW0 use Do trot v r,tEe m; his bection I Y 1 CONDITIONS AND REQUIREMENTS PURSUANT TO G:.L.C.82A AND 520 CMR 7.00 et seq. (as amended) By signing the application,the applicant understands and agrees to comply with the following: i. No trench ntny be excavated unless the requirements of sections 40 through 401)of chapter 82,and any accompanying regulations,have been met and this permit is invalid unless and until said requirements have been complied with by the excavator applying for the permit including,but not limited to,the cstablislament of a valid excavation number with the underground plant damage prevention system as said system is defined in section 76D of chapter 164(DIG SAFE); Trenches may pose a significant health and safety hazard. Pursuant to Section I of Chapter 82 of the General Laws,an excavator shall not leave any open trench unattended without first making every reasonable effort to eliminate any recognized safety hazard that may exist as a result of leaving;said open trench unattended. Excavators should consult regulations promulgated by the Departnent of Public Safety in order to familiarize themselves with the recognized safety hazards associated with excavations and open trenches and the procedures required or recommended by said department in order to make every reasonable etTort to eliminate said safety hazards which may include covering, barricading or otherwise protecting open trenches from accidental entry. Persons engaging in any in any trenching operation shall familiarize themselves with the federal safety standards promulgated by the Occupational Safety and Health Administration on excavations:29 CFR 1026.650 et.seq.,entitled Subpart P`'Excavations". Excavators engaging in any trenching operation tvho utilize hoisting,or other mechanical equipment subject to chapter 146 shall only employ individuals licensed to operate said equipment by the Department of Public Safety pursuant to said chapter and this permit must be.presented to said licensed operator before any excavation is commenced: v. By applying for,accepting and siguring this permit,the applicant hereby attests to the following:(1)that they have read and understands the regulations promulgated by the Department of Public Safety with regard to construction related excavations and tench safety; (2)that he has read and understands the federal safety standards promulgated by the Occupational Safety and Health Administration on excavations:29 C_MR 1926.650 etseq.,entitled Subpart P"Excavations"as well as any other excavation requirements established by this municipality;and(3)that he is aware of and has,with regard to the proposed trench excavation on private property or proposed excavation of a city or town public way that forms the basis of the permit application,complied with the requirements of sections 40- 40D of chapter 82A, vi. This pennit shall be posted in plain view on the site of the trench. For additional hifortnation please visit the Department of Public Safety's website at vvy\v,mass.gov dus. .............. _....._.. .._...... ..... _..._.. . . .._...... .. . .. .. ..... .... ... ... ... . .. 31Pag,e I3/TUE '� 7 M r _C7o_�r�g_,2 , - �� _ r,.I- � �K F..wl I insur��r��e FAI, Igo, 1 �_ 1:�1�4 _��C9 CERTIFICATE O LIABILITY INS �IA �_�� DATE(triMIDD11YYY) 7�?/2013 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 pollcy(les)must be endorsed. If SUBROGATION IS WAIVED, suq)ect t0 the terms and conditions of the pollcy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the cortificate holder In lieu of such endorsements. PRODUCER � NAME:V A & K Fowler Insurance PHONE—(978)664--0366 FAX AiC.No; (918)664-2209 200 Park St. — --° INSURERS?AFFGRDIA:GCOVERAGE �Iq.��N�A_�I_C� _ North Reading M7. D1H6$ INSURERA_N311t21118 Insurwlce Co.� INSJRERBAXbe11,a I-Tut:ual Insurance CO 4. TFC Construction Co. Inc. INSURERCAssoc_iated Industries of MA —� Raymond T. Fraser INSURER 0: P.O. Box 365 -- ---- --— I Danvers bpi 01923 INSURER F COVERAGES CERTIFICATE NUMBER:CL1341601692 _REVISION NUMBER: J THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELCW HAVE BEEN ISSUED-'(-THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VVITH 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.LIM'TS SHOWN MAY HAVE BEEN REDUCED By PAID CLAIMS. POLICY FF (POUCYEXP LTR TYPE OF INSURANCE U13 � POLICY NUTABER•------��rM�A7/D�DIYYY'I) hiOLI C!YYY`( Llydl?S p, GENERALLIABILTY iiN292205 10!26/2012 0/28/2013L� _ -Ew_E 1,UCG,ODO OMMEf, L;E'vEFA !-+EIL ri j I L a � :� � _.� 1 ! PFEdI'E IF 1C0,000 hIE6 F P t nv is----r Ls— 5,000 E° O',L i,Ira,t.R I f 1,000,OOU EfEPI 2E__iATc Is 2,000,000 A�'P LIMIT =S_ — -— — ' _I PEk FI K 'DJ,--T O1.IPrt'PF?„(__ ',000'000 AUTOMOBILE LIABILITY �-�' ��----- ""'�'°'— TO I I ItEa� •:;:�r5 ��`__ 3..000 000 H a L0+' IED (~.{!SCTEUJLED 110X006369 0/19/2012 /19/2013 i rn HI T�., `=-I X f�I PLO':NED EJ.ILY y Ur!(F.r FIPEC..+Il'��;, X;P:TOc � I � I:AIi� ._.. - �.._.r,_rt ��I rins�ri±m?t��r t 615 I. �t rnit 1 I UMBRELLA LIAB �--�------ r- ! Fj-- EXCESS E_C.H r' F QENCE t I rPEoAIE `-- $ r (' WORKERS COMPENSATION AND FMPLOYERS'LIABILITY T-, AIJ'r GFOFRIET02.�tFTt!ER.�YEr'JTIVE((-Y-I��N1 rr. rr�inERtBFR E�.C.UDEC' �_.__1 iN/A' I E L EsC-i yCIL'E�T _ ff 1 000 OGC (Mandatory In NH) P=1026653012012 h/1/2012 7/1/20'13 r' ! t d �rL�eunder ! FE 1- D.El2:E-EwETvlli ( � 1,000,000 C''�-RIP7lJN�F'PEPA`CPISb�I:° !ELL'ISEASE-POLP:'�'-?,11T1'E 0„000 ODO �. DESCF�PTION of OPERATIONS I LOCATIONS I VEHIC!.ES(Attach ACORO 101,Additional Romero sched-.tte.if mars apace Is requlrsd'. Insurance Verification CERTIFICATE HOLDER —�� - CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Tovm of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA AUTHORIZED REPRESENTAri'JE ----- 1 _ K Boutin, CIC CRtd CIS ACORO'25(2010)05] Oo 1968.2010 ACORD CORPORATION. All rights reserved. INS025,.vu(r.o' The ACORD name and logo are registered marks of ACORD