HomeMy WebLinkAboutMiscellaneous - 102 SOUTH BRADFORD STREET 3/3/2017 TOWN OF NORTH ANDOVER Pe Number
NORTH ANDOVER,MASSACHUSETTS 01845
Date ssued
Expir ition Date
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Jackie's Law — Permit Applic ion
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et se .(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CO 4SIDERATION
Name of Applicant (� . &1e-1, Phone Cell
Street Address 6 2at S �'),6 � L ,
Cityfrown MA ZIP
Name of Excavator(if different from applicant) Phone Cell
Street Address
City/Town MA ZIP
Name of Owner(s)of Property/%rte � � Phone Cell
Street Address 16 S. j eL
CityfTown MA ZIP
Other Contact Permit Fee Receivk No Y
Description,location and purpose of proposed trench:
Please describe the exact location of the proposed trench and its purpose(include a dewription of what is(or is intended)to
be laid in proposed trench(eg;pipes/cable lines etc..)Please use reverse side if addition 1 space is needed.
Insurance Certificate ft
Name and Contact Information ofr.
Poh
ky Expiradon Date:
Dig Safe#:
Name of Competent Person(is de ed y 520 CMR 7.112):
Massachusetts Hoisting License# _ d'r76,7
License Grade: f ot — e:x C 4 v +!0 EgjEEAon Date.•
BY SIGNING THIS FO THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE
AND CERTIFY THAT T IEY ARE'FAMILIAR WITH, OR, BEFORE COMMENCEMENT OF THE
WORK, WILL BECOME FAMILIAR WITH, ALL LAWS AND REGULATIONS APPLICABLE TO
WORK PROPOSED,INC] ING OSHA REGULATIONS,G.L.c.CA,520 CMR 7.00 et seq.,AND ANY
APPLICABLE MUNICIPA L ORDINANCES,BY-LAWS AND REGULATIONS AND'INKY COVENANT
AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR SUCH WORK WILL
COMPLY THEREWITH 19 1 ALL RESPECTS AND WITH THE CONDITIONS SET FORTH BELOW.
THE UNDERSIGNED OW 4ER AUTHORIZES THE APPLICANT TO.APPLY FOR THE PERMIT AND
THE EXCAVATOR TO ERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND
ALSO, FOR THE DURA N OF CONSTRUCTION,AUTHORIZES PERSONS DULY APPOINTED BY
THE MUNICIPALITY TO NTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK
FOR CONFORMITY THE CONDITIONS ATTACHED HERETO AND THE LAWS AND
REGULATIONS COVE G SUCH WORK.
THE UNDERSIGNED APP CANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY.
TO REIMBURSE THE CIl'ALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY
THE MUNICIPALITY IN NNECTION WITH THIS PERMIT AND THE WORK CONDUCTED
THEREUNDER,INCLUD G BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE
LAW AND CONDITIONS F THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE
THEREWITH,AND ME S TAKEN BY THE MUNICIPALITY TO PROTECT THE PUBLIC
WHERE THE APPLIC OWNER OR EXCAVATOR HAS FAILED TO COMPLY THEREWITH
INCLUDING POLICE DE AND OTHER REMEDIAL MEASURES DEEMEDNECESSARY BY
THE MUNICIPALITY.
THE UNDERSIGNED API ACANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY
TO DEFEND,WDE AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS
AND EMPLOYEES FRON ANY AND ALL LIABILITY,CAUSES OR ACTION,COSTS,AND EXPENSES
RESULTING FROM OR MSING OUT OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY
PERSON OR PROPERTY I URING THE WORK CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGMA
DATE C L
EXCAVATO SIGNAJ RE(IF DIFFERENT)
DATE
OWNER'S SIGNATURE, DIFFERENT)
DATE: