HomeMy WebLinkAboutApplication - 730 WINTER STREET 5/8/2013 Permit Number
,roWN OP'NORT11 ANDOVFR
NORTII ANDOVER, MASSACHUSFI-I"S 01845
"f Ma WWISS'Lled
-2
Expiration Date
Jackie's Law --- PermitApplication
Pjjlsjj�jjjt to G.L. c. 82A §11 and ,55ZO CMR 7.00 Ct seq.(as a"let,ded)
,rIIIS pt, TO C N DERAT ON
,11i'vill,Nfligrim FuIA,Y(OMPLETED PRIOR 0 Sl I
Name ofAI)JACant 17(k) Phone Cell
t. f .,
Street Address
K "0
MA Z111
Excavator(if differont from applicant) _-I hone C'ell
Street Address
marnax of (s)of Property a Phnxar Coll
Street Address
City/Towil X 11
IV A nO OW v-
Other Contact I'"Received No
flescripiion,location and purpose of proposed trench,
Please describe the exact location of tile proposed trench and its jmrpose(include:a descrilmioll of what is for is intended)to
be laid ill proposed trench(eg;pipes/cal.)je lilies etc_) Please use reverse side if additional space is needed,
7 Y'/l X/) A
Insurance CertitINite 771
�"'-'j 13 9 Y"
ca► l Its a aaxcs °cif atrat wvaµrc 3rta tltrs set tlnir t4'
plalLlfiTT �I'C!T,r,C}'f�1�T113C
ale, n �> ira anon
7777,7
C (,)NDI[I(.yN S AND Eli+,t)IIIREN1E `IS III 1,6(JANT Tt.)(o'.L.C82A AND 520 t"M11 7,00 et wqt
(das aarnended)
'I3y signing the a,pplicatiOn,the applicant underNrtands and a grew to comply with the fialloWira f;:
i.
No trench may be excavated unless the r�c�<�Itrircrarcrrte,ofsections i1()through,Itlfa of chapter 82,arta.l any
accovni anu ,inn re-Actions„have been rraet and this pwilit is invalid unless aand until said requireratients
have been cornpt°retl with by the excavator applying ferr the permit including,but not limited to,the
estaiilishnrcarf of a valid excawition taum1wr with the underground plant d atrrrage pi'L�aentiorl Systearr;gas
staid systern is defined in section 76D ofelintiter 164(DIG SAFE);
91,
frertc:hes may+pose a significant 11ca1th acrd safety hazard, Pursuant to Section i of C°2rtapter 82 of t1w
General Laws,an excavator shall not leave any open trench unattended without first wooing every
reasonable effort to eliminate ally recot"nized safety hazard tlun,many cxist tas as result of icravingr saaid
talaen trench unattended, Excavators should consult regulations pronruloated by the Departrraent of
Public Safety in orcle.r to fianailiaarizea tli.carraselv°es with the rec:o�nizecl safory hazards a c>c-iafetl v^^itta
excavations and open tronolle!;aiml the procci(lures required or recommended by said department in
order to make every reasonable Xc)rt to eliminate said s rt`ety ha;mrds which may include covering,
barric,iding or otherwise protecting opera trenches f orn accidental entry,
iii,
persons eafaging ill ally ill any treachint operation shall t<arrailiaarize;themselves with the f..,d.:rzal stafety
standards prorntrlgated by tire.,Occulaanional and Ileatfh Achninistration on excavations:29 t'"YR
1926 650 et.secl,,entitled Sartipaart 1' `I xc.aav°aatior;s".
iv.
I'xcaavaton.engaging in ally trenching operation who utilize hoisting or other inechauaicaat e gniprnew
subject to chapter 1,16 shall only employ individuals licensed to operate,said ccttaiprnent by file
Dupartrnent of Public Safety pursuant to said Olapter°and this permit must be presented to strict licensed
operator before any excavation is c;omttrenced;
v,
By applying lbr,acccptiaag and ihming this perirnt,ihQ applicant hereby mtests 1c,the t;allowingt:(1)than
they Iraave read and understands the:regulations prollud aafed by(lie Depaartownt offlublrc Saafety with
rc aar°d to ccrnstruotiairt recalled cxcavrations and trench safety", (2'f thaat lie Naas ream and undevstaandv the
federatt safety standaarcts pronurlgated by the Safety and I lealth Administratiaar,on
esxcsavatiovw 29 C'NIR 1926,650 ef,seq,entitled Subpart I'"f,x avmions"as well is any rather
exc aysation requirements established by this municipality;and(3)that lie is aavvare of°arnd has,with
regard to the proposed trench excavation on private plc.)perty or prcmowd excavation of a city or town
public way than forms the basis of the permit application,complied with the realtrir`eraat.raGs of scotions 40-
40f)of ehaapter 82x1.
vi.
'1`his permit shall tie posted in plain view oil the site of the trench,
For additional information pleasas visit:the Department of Public Safety's website at yv�yav r}r,� fir,?r�,lly5
Name and Contact Information of Iusorer.
PolzcyEx ix•atfon l'}ate: _ _.._�.._.__._ _ _.__ ___-__�______-- ---.._— _._ _.,_._______�_.
Di"Sake#:
Fame of Co nipetelzt Person(as defiiked by'520 C MR 7,02):
Ylassarhusetts Iloiitfng License#
License Grade
BY SIGNING TIIIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL AC KNO 'LEDGE:
AND CERTIFY TIIAT THEY ARE FAMILIAR tATI`H, OR, BEFORE CO1VINUNC1FMENT OF THE
WORK, WILL BECOME FAMILIAR WITH, ALL LAWS AND REGULATIONS APPLICABLE TO
WORK PROPOSED,INCLUDING DING OSIIA REGULATIONS, G.L, c. 82A, 520 0111 7.00 et seq., AND ANY
APPLICABLE NIUNICIPAL ORI)INANC'ES, BY-LAWS AND REGULATIONS AND THEY C:`OVE''+NNT
AND AGREE' THAT ALL WORK DONE I N'DER THE P1;RNIIT ISSUED FOR SUCH WORK WILL
COMPLY TH RENVITI-I I!ALL R:ESPEC'I'S AND VITA"IUE CONDITIONS SET ITOTU'II 10"LOW,
TIT, UNDERSIGNED OWNER AUTIIORI'LES THE APPLICANT TO APPLY FOR THE PCRi1•1I'I' AND
THE EXCAVATOR TO UNDERTAKE SIICII WORK ON THE PROPERTY OF TIIE OWNER, AND
ALSO, FOR 'I'IfIt: DURATION OF CONs,rRIIC'TION, ,4L1'I'IIURIZES PERSONS DULY APPOINTED BY
THE MUNK'II'ALITV TO ENTER UPON TI.JE, PROPERTY l'O MONITOR AND INSPECT TIIE' 1Vf.}RK
FOR CONFORMITY WITH THE CONDITIONS A'I'I'AC:III;U II ,REA'O AND THE LAWS AND
ItEG1 LATION'S GOVERI G SUCH WORK,
THE' UNDERSIGNLD APPLICANT,OWNER AND rI,X(`,kVA'rOR kGREI+',7OI'i TI;Y"A.s''D SEVERALLY
TO REIN1 1BI RSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EAPF,NS;ES INCURRED By
TIIE NIT'NICIPALITY IN CONNECTION WTI"U THIS PFRhIIT AND TIIE WORK CONDUCTED
TIIEREUNDI.R,INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUII-UNIF+:i+TS CSI+STATE
LAW AND CONDITIONS OF THIS PERMIT, ASSURE COMPLIANCE
'I'IIf RENVITH,AND MEASURES TAKEN BY TITIf MUNICIPAUTY`TO PROTEC I `I'IIE, I't�IILIC:
WHERE THE APPLICANT OWNER OR EXCAVATOR ITAS FAILED TO CONIPI_,Y THEREWITH
INCLUDING POLICE;DETAILS AND OTHER REMEDIAL MEASURES DI{:,,"A ED NECESSARY BY
THE MUNICIPALITY.
THE I>NDERSIGNE D APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY
TO OFFEND, INDEMNIFY,AND MOLD HARMLESS I'll E INIUNICIPALTTY .AND ALL OF ITS AGENTS
AND EMPLOYEES I FORM ANY AND ALL LIABILITY,CAUSES OR AC-HON,COSTS,LAND EXPENSES
RESL'L`"ING FROM OR .•ARTSC G OP'`I' OF ANY INJURY, UATIT, LOSS, OR D. IMAGE TO ANY
PERSON OR PROPERTY D"URING TIfI WORK CONDUCTED UNDER TITS I'ERMITI
APPLICANT SIC NA`"U'RE
EXCAVATOR SICrNATI IRE(IF DIFFERENT)
SATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE-
21 P V