HomeMy WebLinkAboutMassDOT Permit - - 1210 Osgood Street �u
IK 1 le,u tier d i
�
;Massachusetts Oepartment of r
l I jj�f ir ansporUtlan
II i
��
PERMIT- NORTH ANDOVER
Drivcwa r(s) (Residential), Driveway(s) (Commercial),Transportation Improvement
Permit : 201 - 19
Subject to all the, terms.,conditions, and restrictions printed or written below,,, permission
is hereby granted to F+ R+GETTA► DEVELOPMENT, LLC to enter upon the State
Highway known as ROUTE 125 OS GO D STREET) for the purpose of performing the
following work related. to#1210 Osgood Street - Mixed Use Development (15,000-square
feet SF of residential apartments, 3, 00-SF of retail space, an 8,000-SF office, a 3,000-
SF lank, and a 7,400-" restaurant). All work is to be done as shown on the plans
submitted and on file in the District Four Permit Office by Vanas a and Associates, Inc.
titled "Transportation Improvement Project, Plan of Osgood Street (Route 1 at Barker
Street, in the Town of North Andover, Revised PS E Submittal" dated June 29, 2018.
All work shall be in accordance with the M.G.L. Chapter 30,Section +61 .Finding for 121
Osgood Street, EErA Number 1 300 dated January 1+7,201811
Prior toocommencing work, the recorded layout alteration shall be submitted to the
Disitriet Four Permit's Office. A .state highway layout alteration including change in
access designation has been scheduled for recording for the Route 15 (Osgood Street) at
the Registry of Deeds. Layout No. 631--Alteration of State Highway (known as Route
1 5) in the Town of North Andover.
Site access improvements will be implemented ed by the Town rf North Andover as part of
the MassWorks grant project.
Driveways:
*Constructing two driveway approaches utilizing vertical granite curbing '+GQ, the first
driveway approach located at the intersection of+Osgood Street and Barker Street between
approximate stations 1 1+49 and I +l I at the northwesterly location line and flaring to
approximate stations 131+22 and. 13 +41 at the edge of the roadway.The second driveway
approach between approximate stations 141+15 and 141+6"7 at the westerly location line
and flaring to approximate stations 140+ 0 and 14 00 at the edge of the roadway.
Roadway Improvements.
•Perf+orming roadway improvements between approximate stations 106+00 and 147+00
including widening of Osgood Street for 5-foot shoulders, constructing sidewalks on both
sides of O good Street, *Installing pavement markings and signing plan including exclusive
left turn lanes on Osgood Street northbound and southbound at the proposed main site
driveway and Barker Street and other associated work including full depth pavement,
cold planing and resurfacing, resetting curb and edging, drainage system improvements
and loam and seed.
Page 1 of g
MassD 0 T ,,High waV Division -District *519 Appleton Street,Arlllzgton, MA 02476•( 1)6 1- '300
Traffic Signal Improvements:
&Performing traffic signal i* •mprovements including the installation of trafflic signal on
Osgood Street at Barker Street and Main Site Driveway (Draft Traffic Signal Control -
Regulation No. AB-210-3090)and traffic signal timing modifications at thel"ntersections of
Osgood Street at Great Pond Road (Draft Traffic Signal Control - Regulation No. AB-210-
3091) and Osgood Street and Sutton Street (Draft Traffic Signal Control - Regulation No.
AB-210-3089),
Per the MUTCD, ■Section 4C.01, the Proponent will conduct an engineerl'ng study be done
w i*th* I • I I I in one year of the start of operaflon. to analyze justfflcafion of the traffic signal. In the
event that the signal I*s not justiffled, 'it should be taken out of stop-and-go mode or
removed.
WORK HOURS: 9:00 A.M. thru 3.,POO P.M. Monday thru Friday.
The Grantee shall not engage in any signalization work under benefit of this Permit unti"l
the appropriate Traffic Signal Regulation and Utility Agreements have been both
approved and si*gned by the Boston Office.
The Grantee/Applicant shall record any Vehicular Access Permit or any Non-Vehicular
Access Permit involving drainage at the appropriate registry of deeds. Any Permit 'Issued
by MassDOT that requires recording shall not be effective until recorded at the
appropriate registry of deeds and a nofice or recordingj*s submitted to the District
Highway Director.
The Grantee shall not engage in any utifity work under benefit of this Permi"t, Nothing in
this Perml*t shall be construed ■as authorizi 1*ng any installation. or mal'*ntenance thereof. For
all driveway/roadway applications 0 0 0 requiring utilities (water,gas,sewer etc.),a separate
Permit must be applied for by the appropriate Utility Company or Municipality.
The Grantee shall not engagein any work under benefit of this Permit until a MassDOT`
Roadway Work Notification Form (attached) 'is ri led w ith the Distri ct Pe rml'*t Office prior
to the start of work.The form must contain the requl*red information and have the proper
signatory approval. The form must be submitted no later than 12:00 PM on the
Wednesday prior to the week the work will begin.The duration of work approvals shall
be limited to one week at a time. If the work exceeds one week then a new Roadway Work
Notification Form is required to be submi'tted for each additional week. The Grantee can
fax the completed form to MassDOT at 781.646.5115.
The Grantee shall notify the District Perml*t Office at 781.641.8351, two (2) working days
prior to the start of work. No work shall be authorized without said notification.,
The Grantee shall contact the Area Contact Person (7:30 AM to 4:00 PM Monday
through Friday) at 617.279.7203, two (2) working days prior to the start of work.
Prior to commenct*ng work relative to road wl'dening and/or the installation of traffic
control devices,the Grantee shall obtain the services of a qualified engi* aneering consulting
Page 2 of 9
provide ■ # ■ duration
tirm,acceptable to the Department, to
on throughout the
of the project. The Grantee shall notify the District 'in writing of the consultant contact
person, name, address and telephone number. This designee shall submit weekly reports
to the District Four Permits Office summarizing daily activities and progress.
The Grantee shall also obtain the services of a qualified engineering consulting firm,
acceptable to the i to #de F ♦te W M
Department, nuous
on of any traffic
signal,
highway lighting, flashing beacon, illuminated
other electrical work or traffic
sign,
progress.management associated with this.project. This consultant shall be present during all mast
arm,strain pole and controller cabinet foundation installations to 'insure proper location,
orientation and conformance to design standards. This consultant shall submit weekly
reports to the District Four Permits Office summarizing daily activities and The
requirements of this and the preceding paragraph can be combined and completed by the
same consultant,, provided the consultant 'is acceptable to the Department.
a • ■ • s ■
inspectionThe Grantee's project traffic design engineer shall provde shop drawng review, final
IN IN # resolution electronic as-built r Signal
approved.signal
st
work will not be accepted until all outstanding punch list items have been addressed and
as built drawings are submitted to the District Four Traffic Engineer in the standard
signal 'Inventory format and software version and
Whenever work is to be done within two hundred (200) feet of existing.State Highway
Traffic Signals, the District Office must be notified by the Grantee at least two (2)
a * r
working days
or to the start of work by
ng the District Four Traffic Office at
r r r
PermitThe Attached Trench Rider 'Integral
conditions
a a i
r
PublicThe Grantee shall not engagein any trench work under benefit of this Permit until a
Department of Excavation ' r
is riled
District.Permit Office two (2) working days prior to the start of work. The Grantee can
fax the completed form to MassDOT at
th the
The Grantee(s) must adhere to 520 CMR
00; EXCAVATION AND TRENCH SAFETY
5115.
Public ■ conjunction
■ # 4 • •
as promulgated by the Department of
in
th the
on of
Occupational Safety pursuant to the authority granted by
M.G.L.
A copy of i i Job
r inspection. Failure
t must be on the
te at all times for
• r • ■ • ■
it avalable wll result in suspension I
perm
of the
ghts granted by
s permit until such
s ■s made i
r
CompletionThe possible
completion
physical
work.
protective safety equipment while working wl*thl*n the project limits. This equipment shall
■ minimum,
i * being
include,as a
a hardhat and a safety vest, regardless of the type of work
J
equipmentperformed. Other safety
required
non-reflecting
which they are engaged and in accordance wl*th all local,state and federal requirements in
The Grantee shall utilize and pay for uniformed police officers wl*th their official vehicles
to be in attendance at al I t imes while work 'is bei ng done under this permit.
The furnishing and erecting of all required signs and traffic safety devices shall be the
Nflty of the Grantee.
All signs and devices shall conform to the 2009 edition of the Manual on Uniform Traffic
Control Devices (MUTCD) with the Commonwealth of Massachusetts Amendments.
Cones and
ceased.highway when the daytime operations have
If it becomes necessary for this
Department to remove any construction warning devices or their appurtenances from the
project due to■ negligence #
minimized.
ll be charged to the
Itis imperative that construct-ion operations are managed so that motorists travel "delay"
is At any time dur.ing the operation when a traffic delay of over twelve (12)
minutes occurs and the• situation
r r ■ the Grantee worsening, ■ begin
■ • . # ft
operat
ons,
nuously
increasing
delays" of over twelve (12) minutes are not to be
permitted and may result in the suspension of the operation or termination of this Permit
by the Department@
Flashing arrow boards will be used at all times when operations occupy the roadway and
shall be ■ able for use at all ■
•
Engineer,All warning devices shall be subject to removal, replacement and repositioning by the
Grantee as often as deemed necessary by the
# existing
;
Care shall be exercised so as not to disturb any
s W loops are disturbed, they shall be restored immediately after the end of the work day
al
to their original condition. All expenses for restoring conditions shall be borne by the
The splicing
i is
within
#
layout.
Sidewalks Wheelchair
and Regulaflons of the Architectural Access Board (AAB) and Americans with D16abilities
Act (ADA), (Sections
and the ■ i
'1
r Ramp Standards
revised.booklet effective 10/8/97, and the
on and Traffic Standards Details, 1996 Metric
Edition as
sidewalkAfter the prepared, a foundation of gravel shall be placed
■ i 4 foundation
. After
mectianically compacted thoroughly the
upon 1
• in
F J
disturbed,inches
ckness and parallel to the proposed surface of the walk.
The bituminous concrete sidewalk surfaces shall be laid in 2 courses to a depth after
rolling of 2 1/2 inches. The bottom course shall be 11/4 inches in thickness and 'Its surface
after rolling shall be 1 1/4inches below the parallel to the proposed grade of the finished
surface. The top course shall be 1 1/4inchesin thickness after rolling,
If the sidewalk area is
it shall be
full width, in kind a minimum of rive
restored,
disturbedfeet beyond any
DirectorAll pavement markings shall be thermoplastic.
All existing pavement markings proposed to be removed shall be removed completely by
It shall be the responsibility of the Grantee to replace all pavement markings which have
been disturbed by this permit. These pavement markings shall be restored within ten (10)
days after this work is performed or as deemed necessary by the District Highway
authorized Representative,
# $ during construction,
If corrugated metal
nage pipe (CMP)
s disturbed
shall remove and replace all CMP from structure to structure with either Reinforced
Concrete ipe (RCP) or i
gh Density Polyethylene (HDPE).
The Grantee shall utilize
f Density 4 in
• replacing
ll (CDF)
eu of
base encountered within the project area.
The Grantee shall utilize Controlled Density Fill (CDF) for this installation whenever
lateral trenches are cut in
A permanent patch shall then 4 • �
nstalled4 The pavement shall be cut in a neat truesurface,
ne
one foot outside all limits of the excavation within the roadway
then excavated to
thickdepth of seven and one-half'Inches (7-1/2"). The base course shall be three and one-half
inches (3-1/2") thick of SUPERPAVE Base Course Pavement -37.5.The intermediate
course shall be two and a quarter inches (2-1/4")
Lastly, the surface course shall be one and three-quarter inches (1-3/4") thick of
At the completion of the work the Grantee shall cold plane 2" full width, gutter line to
# ■ i
SUPERPAVE Surface Course -
gutter l a minimum of 30 feet beyond any disturbed area and resurface with 2"
prior to the work.
The crown of the roadway shall be restored to a condition equal to that which existed
Page 5 of 9
Provisions shall be made for the safety and protection of Pedestrian Traffic during the
construction period.
It shall be the responsibility of the Grantee to provide access to the property of residents and
business owners during the progress of the proposed work.
Under no circumstances shall the operations create a hazardous environment for the general
public.
The Grantee shall notify Dig-Safe at 1.888.344.7233 at least 72 hours prior to the start of work
for the purpose of identifying the location of underground utilities.
Dig-Safe# To be obtained prior to the commencement of work.
All utility companies whose services are located within or adjacent to the proposed installation
areas shall be notified in writing of the proposed installation at least 48 hours prior to the start of
any excavation in said areas. This is independent of the required dig safe notification.
All work shall be 'in compliance with the 1988 Edition of the "Massachusetts Highway
Department Standard Specifications for Highways and Bridges", and Supplemental
Specifications Dated July 1, 2015.
No equipment, trucks, workers, etc., shall occupy any part of the traveled way except between
the hours of 9:00 A.M. and 3:00 P.M. Monday thru Friday. Except for an emergency', in no case
will operations exceed the specified hours without the prior approval of the District Highway
Director or an authorized Representative. This includes the placement of traffic control
devices, vehicles, equipment or anything that restricts the flow of traffic through the
construction zone. Emergencies must be unexpected situations or sudden occurrences of a
serious and urgent nature that demand immediate attention.
No work will be performed on the day before or the day after a holiday or a long weekend which
involves a holiday on any highway, roadway or property under the control of the MassDOT
Highway Division or in areas where the work would adversely impact the normal flow of traffic
on the State Highway System, without permission of the District Highway Director or an
authorized Representative.
Two way traffic shall be maintained at all times.
When in the opinion of the Engineer, this operation constiffitutes a hazard to traffic in any area,
the Grantee may be required to suspend operations.during certain hours and to remove his
equipment from the roadway.
The Grantee will be responsible for any damage caused by this operation to curbing, structures,
roadway, etc.
No work shall be authorized during snow, sleet, or ice storms and subsequent snow and ice
operations.
Page 6 of 9
No bituminous concrete shall be installed between November 15th and April 5 h without prior
approval from the District Highway Director or an authorized Representative.
The State Highway Layout shall be kept clean of debris of any nature at all times and shall be
thoroughly cleaned at the completion of this permit.
a
At the completion of this permit, all disturbed areas shall be restored to a condition equal or
better to that which existed prior to the work.
Any grass areas disturbed within the State Highway Layout shall be graded, loamed to a depth
of 4" and seeded.
The Grantee shall assume full responsibility for the structural integrity of any trench described
in this Permit.
The Contractor, when opening -nis trench on bituminous material or concrete surface, shall
either use a Jack-hammer or saw to 'insure the least amount of damage to the roadway surface
a
and keeping the edges of the trench somewhat parallel in a straight fine.
After the work has been completed the Grantee shall use the Infra-Red Method as a surface
treatment a minimum of one (1) foot beyond the limits of the trench.
The Grantee shall be responsible for any settlement which may occur as a result of the work
0
done under this permit.
The Grantee shall assume full responsibility for the structural integrity of any trench described
0
in this Permit.
The Grantee shall respond to trench maintenance requests by the District Highway Director or
an authorized Representative within two (2) working days. Non-response within the specified
time will result in the required maintenance work being done by the Grantor, with all the
expenses charged to the Grantee.
Failure to respond to trench maintenance shall result in denial of future Permit requests.
The Grantee shall be responsible for any ponding of water which may develop within the State
Highway Layout, caused by this work.
If the Grantee elects to use steel plates to protect the excavations, they shall be of sufficient
thickness to resist bending and vibration under traffic loads, recessed and set flush with the
adjacent roadway surface, and shall be anchored securely to prevent movement. Class I
Bituminous Concrete Pavement shall be placed around the steel plates to provide a smooth
transition between the plates and the roadway. If these conditions are not met the Grantee will
be required to back fill and pave the excavations daily. No trench shall be left open during non-
working hours.
Page 7 of 9
Steel sheeting, shoring or bracing shall be driven or placed for all depths over 5 feet. At the
discretion of the State Engineer said sheeting shall be left in place and cut off two (2) feet
below the surface.
Any grass areas disturbed within the State Highway Layout shall be graded, loamed to a depth
of 4" and seeded.
If the existing guardrail i's removed or damaged it shall be reset or replaced to MassDOT
Standards. This work shall be performed by an approved contractor.
It shall be the responsibility of the Grantee to replace all pavement markings which have been
0
disturbed by this in
permit These pavement markings shall be restored with
. ten (10) days after
this work is performed or as deemed necessary by the District Highway Director or an
authorized Representative.
Any bound marked MH13 shall not be removed or disturbed. If it becomes necessary to remove
and reset any highway bounds then the Grantee shall hire a Registered Professional Land
Surveyor to perform this work. It shall be the responsibility of this land surveyor to submit to
this office a statement in writing and a plan containing his stamp and signature showing that
said work has been performed.
The Grantee assumes all risk associated with any environmental condition within the subject
property and shall be solely responsible for all costs associated with evaluating, assessing, and
remediating', in accordance with all applicable laws, any environmental contamination (1)
discovered during Grantee's work or activities under this permit to the extent such evaluation,
assessment or remediation is required for Grantees y
's work, or (2) resulting from Grantee's work
or activities under this permit. Grantee shall notify Grantor of any such assessment and
rernediation activities. The Grantee is hereby held solely responsible for obtaining and
maintaining any and all environmental compliance permits required by local, state and federal
laws and regulations when regular or emergency work is proposed within, or in close proximity
to, any wetland area.
0
This permit 'is issued with the stipulation that it may be modified or revoked at any time at the
discretion of the District Four Highway Director or an authorized Representative without
rendering said Department or the Commonwealth of Massachusetts liable in any way.
The Grantee shall indemnify and hold harmless the Commonwealth and its Highway Division
against all suits,claims or liability of every name and nature arising at any time out of or in
consequence of the acts of the Grantee in the performance of the work covered by this permit
and or failure to comply with terms and conditions of the permit whether by themselves or their
employees or subcontractors.
APPLICANT'S REPRESENTATIVE: Steve Boudreau,PE
TELEPHONE NUMBER. (978)474-8800
Page 8 of 9
I '
01TIIIW�I'
IIII
7
�V
/%���/i��l(!6 rr
ll I q�- I I i II III I
��,,;Baia,,,,,✓iiiiii�������i�i/iii/�/////�//���i i
ay
TRENCH PERMIT RIDER
Pursuant t0 G.L. es. 81, §21 and 82A §1, 720 CMR 13.00 and 520 CMR 7.00 yet seq
THIS PERMIT MUST B E P ULLY COMPL ETE D PRI+[ R TO CON IHIIR.ATIt N
ame of Applicant Phone Cell
Street Address
City/Town ZIP
ame of Excavator(if different from applicant) Phone Cell
Street Address
City/Town MA
m�mioioimmoioioioioioioioioioioiomn
•
■ I
+ II �
ZIP
Name of Owner(s)of Property Phone Cell
Street Address
City/Town MA ZIP
IN
Other Contact Permit Fee Received
�,n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n� mioioioimmomimnemmorn�m�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�
r
������ �mm n�rn�nnn�nnn�rn�n�n�nm�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n
I�� ���I' I���I III
ni��Inin Om �i�n�n�n�n�n���lnnn�m��n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n���n�n�n�n�n�nd m�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�mn�n�n��nm�nm�n�nm�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n
+
Please describe the exact location of the proposed trench and its purpose(include a description of what is(oris intended)to
be Description,location and purpose of proposed trench:d'in proposed trench(eg-; + r
dlll .. .
�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n� ioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioio.n�moioioiomrn�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n+�n�n+�n�mmion
Insurance Certificate N:
Name and Contact Informatioit of
�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n��nin��inininimm��n�n�n�num�n�n�n�n�n�n�neon�momomioimnm�nmioioimn��ininininininimmom�mom�n�nnn�n�n�n�mm mmoiom�mioiomneommn�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�mm��n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�
Insurer:
�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n��nioioioioioioioioioioioioioioioioioioioioiom�moiom� �n�n�n�n�n.mrrrrnrrmmeomioomimn�nuomuoioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioimmioioioioioioioimnmomn�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�nrrrrrrnrrimm
*ration Date.
n,n, jn�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n n�n�
� in ioioioioioioioioioioomonmon�n�n�n�moimmm�om�n�n�neon�n�miomioioioioioioioioioioioioioioioioioioioioioioioioimmoioioioioioioioioioioioioioioioioioioioioioioioioioioiomn�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�nmrn�n�n�mn�n�n�n�n�n�n�n�n�n�n�n�n�n�mm��n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�noin�+mmmmm�n
Dig Safe
r ;
mioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioioiom�n�n ioioioioioioioioioioioioioioioioioioioioioioioioioioiom�n� ioioioioioioioimmmn�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�mon�n�n�n�n�mn�n�n�mmmrrrrrr+.+mm�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�
Name of Competent Person(as defined by 520 CMR
Rn tl
immnn�mm��n�n� emn�nmmn�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�nrmmrr.mmmmnrmn�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�n�
... ... .... .,iuim,w^mumuuomumuouououornRmm^imnmui mr d... a. a.a.. ana... o....... ..fo.4 ..fo.4 ...o.o. ..w.w muuu uwlm ......o .....fo o ......i�xw,www a yuuu u..� .. g�ilq u u u u u uoury,nun o ou pyu o uo uo uo VP.0 u u u u u u uP.,o VIII o.................................rrrrl.f� d
Massachusetts ois in License
Licens e G ra de� ,it ti a Date.-
. ............................................................................................................................... ......... ..........................««rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr �wrr � �
BY SIGNING THIS FORM,THE APPLI+CANT'AND EXCAVATOR ACKNOWLEDGE AND CERTIFY THAT THEY ARE
FAMILIAR WITH,OR,BEFORE COMMENCEMENT THE WORK,WILL BECOME FAMILIAR WITH,,ALL LAW
AND REGULATIONS APPLICABLE TO WORK PROPOSED, INCLUDING OSHA REGULATIONS, G.L. C. 82AI, 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 APPLICANT AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO REIMBURSE THE
COMMONWEALTH FOR ANY AND.ALL COSTS AND EXPENSES INCURRED BY THE COMMONWEALTH 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,
IN P CTION'S MADE TO ASSURE+COMPLLANCE THEREWITH.AND MEASURES TA EN BY THE
COMMONWEALTH TO PROTECT THE PUBLIC WHERE THE.APPLICANT OR EXCAVATOR HAS FAILED TO
COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED
NECESSARY BY THE COMMONWEALTH.
THE UNDERSIGNED APPLICANT" .AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDEMNIFY, .AND HOLD HARMLESS THE COMMONWEALTH 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 SIGNATURE
DATE
EXCAVATOR SIGNATURE IF DIFFERENT
DATE
n.o
;
,.,«Faa�,..,ara,rr ..1 ✓//r r..( ✓r.riwrl,r. ,rl,..nir�,riii, ir�.., ��.,,i,,l, ,..,. 1...,., i. ry ...,.r;<: m tel
/'uNIAIIInuwiu wri�J l gNlrkhl�Nr+rdYN>l�ilk1 IMN �roaa urnmmWiuimarv�ttrem�umcmmiwrmmremrmiKacruwaiuvu mrvii}mwummrvwii>�wuwtiDiup ',arrr+wwnawwuiwamuauuwuwuWNuuwwsuwuu}ww�nweuwwWinuWwwuvurwruuyarwaiuuuwuiuuwuuwuwwu
_, s,. r ;rc:. o ,, i ,✓:i „, � .„ „ar, ,i., i r,. as o,..
�r
,a
NdflY(�N � metre met ✓ r o/%%/ /a
r
u aaa r i, o r r r
%///
a
rti» //W,: H��W�rW1Yl�urv6mrIFNWIIimrra( rrmP/n um��mY i ma miim' mmaacnm w a met remmmm iumf ii i i 1fJ�iY � � � n `'mimro mtta a u ri uwuuru� rii a
�l
i
/o iii r Uri r ill,o rii / o ri a r i
i aaaa
o / c„r ai ii r i aai a Tali,,, r ii / � aia i,
i
i ,,,,,,,,> r as
� % ,,,,,, Wit/
/ as / /
/ %/ ,,, ,
/ i in N
r /i as c //„
...., r /. �///i� %/
r / i � / / � �„ / �ui, � rill a. ii a r r
+CONDITIONS AND REQUIREMENTS PURSUANT TO G.L.C.82A AND 520CMR 7.00 et seq. as amended,
By signing the application,the applicant understands and agrees to comply with the following:
0 0
1 No trench may be excavated unless the requirements of sections 40 through 40D of chapter 82,and any accompanying
ffi
regulations,have been met and this permit is invalid unless and until said requirements have been compiled with by the
excavator applying for the permit including,but not limited to,the establishment 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);
06
n 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 Department 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 effort to eliminate said safety hazards which may include covering',barricading or
otherwise protecting open trenches from accidental entry.
*OR
in 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 191.6.650 et.seq.,entitled
Subpart P"Excavations".
iv. Excavators engaging in any trenching operation who 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
s id chapter and this permit must be presented to said licensed operator before any excavation is commenced;al I I ] 1 9
v. By applying for,accepting and signing this permit,the applicant hereby attests to the following:(I)that they have read
ffi
and understands the regulations promulgated by the Department of Public Safety with regard to construction related
excavations and trench safety; (2)that he has read and understands the federal safety standards promulgated by the
Occupational Safety and Health Administration on excavations:29 CMR 19.2.6.650 et.seq.,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
publ 1 c way that form s the bas is of the perm 1 t appl ication,compi i ed with the req u i rements of sections 40-40 D o f chapter
82A.
vi. Th I s pe rm 1 t shal I be posted i n plal n view on the s Re of the trench.
For additional information please visit the Department of Public Safety's website at J[
Summa cavation and Trench Safety Re ulation(520 CMR 14.00 et seq.1
This summary was prepared by the Massachusetts Department of Public Safety pursuant to G.L.c.82A and does�not include all
requirements of the 520 CMR 14.00. To view the full regulation and G.L.c.82A,go to www/mass,,gov/dps
Pursuant to M.G.L.c.8.2, § 1,the Department of Public Safety,jointly with the Division of Occupational Safety,drafted regulations
relative to trench safety. The regulation is codified in section 14.00 of title 520 of the Code of Massachusetts Regulations,The
regulation requires all excavators to obtain a permit prior to the excavation of a trench made for a construction-related purpose on
public or private land or rights-of-way. All municipalities must establish a local pennitting authority for the purpose of issuing
permits for trenches within their municipality.Trenches on land owned or controlled by a public(state)agency requires a permit to be
issued by that public agency unless otherwise designated.
W , 0
In addition to the permitting requirements mandated by statute the trench safety regulations require that all excavators,
whether public or private,take specific precautions to protect the general public and prevent unauthorized access to unattended
trenches Accordingly unattended trenches must be covered barricaded or backfilled Covers must be road plates at least
. , , . thick or
equivalent-barricades must be fences at least 6" high with no openings greater than 4""between vertical supports-backfilling must be
su ffici ent to el im 1 nate the trench. A Iternati vely,excavators may choose to attend trenches at al I ti mes,for instance by h 1 ri ng a pol i ce
detail,security guard or other attendant who will be present during times when the trench will be unattended by the excavator.
The regulations further provide that local permitting authorities,the Department of Public Safety,or the Division of
6 6
Occupational Safety may order an immediate shutdown of a trench in the event of a death or serious injury;the fal lure to obtain a
permit-,or the failure to implement or effectively use adequate protections for the general public. The trench shall remain shutdown
u 'I nti -reinspected and authorized to re-open provided,however,that excavators shall have the right to appeal an immediate shutdown.I
Permitting authorities are further authorized to suspend or revoke a permit following a hearing. Excavators may also be subject to
administrative fines issued by the Department of Public Safety for identifled violations.
Summary of 1926 CFR Subpart P JIdKOSHA Excavation Standard
This is a worker protection standard,and is designed to protect employees who are working inside a trench. This summary was
prepared by the Massachusetts Division of Occupational Safety and not OSHA for informational purposes only and does not constitute
an official interpretation by OSHA of their regulations,and may not include all aspects of the standard.
For further information or a full copy of the standard go to
16.011S
• Trench Derinition per the OSHA standard:
(1 An excavation made below the surface of the ground,narrow in relation to its length.
A In general,the depth is greater than the width,but the width of the trench is not greater than fifteen feet.
• Protective Systems to prevent soil wall collapse are always required in trenches deeper than 5',and are also required in
trenches less than 5"deep when the competent person determines that a hazard exists Protection options include-
. ,
o Shoring. Shoring must be used in accordance with the OSHA Excavation standard appendices,the equipment
manufacturer's tabulated data,or designed by a registered professional engineer.
o Shielding(Trench Boxes). Trench boxes must be used in accordance with the equipment manufacturer's tabulated
data,or a registered professional engineer.
o Sloping or Benching. In Type C soils(what is most typically encountered)the excavation must extend horizontally
I 111111i feet for every foot of trench depth on both sides, I foot for Type B soils,and 3/4 foot for Type A soils.
•o A registered professional engineer must design protective systems for all excavations greater than 20" 'in depth.
•
• Ladders must be used in trenches deeper than 4'.
o Ladders must be inside the trench with workers at all times,and located within 25' of unobstructed lateral travel for
every worker in the trench.
o Ladders must extend 3"above the top o f the trench so workers can safety get onto and o ff o f the I adder.
Inspections of every trench worksite are required.-
o Prior to the start of each shift,and again when there is a change in conditions such as a rainstorm.
o Inspections must be conducted by the competent person(see below).
Competent Person(s)is.,
o Ca a le(i.e.,trained and knowledgeable) in ldentlf�lng existing and predictable hazards in the trench,and other
working conditions which may pose a hazard to workers,and
o AuthorizeiLby management to take necessary corrective action to eliminate the hazards. Employees must be
removed from hazardous areas until the hazard has been corrected.
Underground Utilities must be-,
Identified prior to opening the excavation(e.g.,contact Digsafe),
iff Located by safe and acceptable means while excavating.
irr Protected,supported,or removed once exposed.
Spoils must be kept back a minimum of'.2" from the edge of the trench,.
Surface Encumbrances creating a hazard must be removed or supported to safeguard employees. Keep heavy equipment
and heavy material as far back from the edge of the trench as possible.
Sta bill ity of Adj acen t Structu res:
airy Where the stability of adjacent structures'is endangered by creation of the trench,they must be underpinned,braced,
or otherwise supported.
Sidewalks,pavements,etc.shall not be undermined unless a support system or other method of protection is
p 'ded.
rovi
Protection from water accumulation hazards-,
It is not allowable for employees to work in trenches with accumulated water. If water control such as pumping Is
used to prevent water accumulation,this must be monitored by the competent person.
c If the trench interrupts natural drainage of surface water,ditches,dikes or other means must be used to prevent this
water from entering the excavation.
Additional Requirements:
For mobile equipment operated near the edge of the trench,a waming system such as barricades or stop logs must be
used.
o Employees are not permitted to work underneath loads. Operators may not remain in vehicles being loaded unless
vehicles are equipped with adequate protection as per 1926.60 1(b)(6).
ic'! Employees must wear high-visibility clothing in traffic work zones.
C Air monitoring must be conducted in trenches deeper than j if the potential for a hazardous atmosphere exists. If a
'>'7 1� A" LEL,specific chemical hazard),adequate
hazardous atmosphere is found to exist(e.g.,0,<"19.5%or'!,',' B.501,r'; "ORr6
i protections sh al I be taken such as vent 1 lation of the s pace.
Walkways are required where employees must cross over the trench. Walkways with guardrails must be provided
for crossing over trenches 6' deep.
C�"A Employees must be protected from loose rock or soil through protections such as scaling or protective barricades.
i
I
MASSACHUSETTS
Roadway Work Notification Form Page: i of 2
Start Date: Start Time: ridDate",: Fred Time,
............................................................................................................................................................................................................................................
El El
No. Bri ge nspecox,'m
Permit Project.No. El Other:
0 0 0 0 0
Roadway. Direction: NB SB EB WB OTHER
From. To-D
hiterseciing Street) (Exit#or hitersecring Street)
Bridge No.. over
W qvµ., ® q 7 a q Railroad Other)
i r
Ramp Closures. Direction) (Roadway&Direction)
Brief Description of Work: (Attach second sheet for multiple lane closures or additional information)
e s a o
-------------- ..................................................... ........... ..................... ---------------------- .................... ------------------ ������ww'.mumnoow000w000w000w000w000
S Shoulder
Z L Travel Lane
M Median
w000w000w000w000woom����� --------------------------------------------------- -------------------- .................... ------------- ------------ ------------------ ...................
........................................................................
........
wnwoow000w000w000w000w000w0000w000w000w000w000w000rvon�wooreroow000�m�woo�ummmm -----------------------....................... ...................... ......................
Ciiiian'tact Person:
--------------------------------------------------------------------------------------------------a AMMI----------------------------------------------------
111C"el I I III 1 l :
�� ��.................................................... --------------------- ------------------------------,
Phase One
000 0 0
Roadway* Direction: NB SB EB WB OTHER
Page 2 of 2
"JMIW'?'h7YJ9YJ9YJ.:,M!YM,"r1'fiFA.,,,., 'rPfl'Alm'A'IIMNIIII,"W,x'. ,, MIMMIRN100Mtl ,9F4Af0AIlAlI�V '9PJIMI OW6Y,ffi'!r!l'!!'!!'!!'!!'!!'!!'!!'llrrrrrrrrrrrrrr!!!!!!!lldlfirdlfirdl ",,,,, ,,,,"„ta'6�rddF6fiddldldldddddddd'F!!!!!!!!!!!!!!!J!!!'!!llillrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
Brief Description of Work: (Attach second sheet for multiple lane closures or additional information)
76- ga)
MlmM'i Mmrvm�Mm�mou�r�mmtM
u l
L = Travel Lane
Ix ' r 1
n nininininnnnnnnnn nnn i im Y,. „1F'^r+/�1�',Y�XII��IrbXlnrwr," lr rr..!'r.............................................
Y Y Y Y ..yx .
i
cc
I 4
r
........................
Phase Two
District: City/Town:
- �,��.�,��, �,��.�,��, �,��.�,��, �,��.�,��,�,��.�,��� ,,,,,,,,�.:y('driX��VHFi151515��I✓i�d1Y�14YlYlYr�vf�i�rwn!nrr»«��mmnnamrmrhm�envraammmnmsrs+m�arm,�yr�yr�u.ro�+rar�aro�amm�mnm'rinrir�cmmrnrcru�mmm�uw'rvrva�rn'mm»mronr�rvmmmmmio
0 0 0 0 0
Roadway• ir+ection: I" B SB EB B OTHER
in�mrr����mvrvrmrmrnm'rv�rem!'rv�r��mnrmmm,!rrnm;rv�rrr' '' drrr �c�ddrr�drrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrddrsr�,d ..''' .'rmFrcjjJu,,,JydYryjFFyYYYYYr�,YrlYiinrilN��'
Brief Description
i Work: (Attach additional
iu
tM
������������������������������ o ������� ������������������������������������������������ waver, ,,,,,,... ,,, ,.,,firsd�drr�,ddsr�,ddsr�,ddsr�,d�drd,��awrfirrrrdrrrrdrrrrdrrrrdrrrrr' ,,,,,,,,,, ,:,bflxIkr„.„r�,uX'dF36LF�Y�»iL rvmrr ,.,.,,✓roti;�rr „rm� r�n�r�,.. I -., ,,,,,.,.,. „�arfirrfinrr'
i
S = Shoulder �
Z L = 1 1
Travel Lane
� a
������� luuuuuuuuu IbVlu ,, ', �drxdrudc�rd�drtr�r�r�r�r�aurcurcrdar�rdur «drdrdrdrddrtrrrr y, ,y
i
Co
�{ 1
_I
°����oo�lllllllllll
4mFllll�����
i.3s
Kary III,, lI � � I I u�I rian eve � �rI
Stephanie Pollack dJonathan L Gullliver,ew.N�w1p� o��u ��WU�iu IW��IHighmay Administrallior Fn,� sDOT
I ��� III I� I o� ��� I� �� I I
4f moon I �
lio ��liii �
Completion
You may proceed • described r within rthe Massachusetts Department of r a
Transportationth the work
s Permit, which has been 'issued to you by
(MassDOT).
Your attention a is
* r a extension
me frame allowed for completion of said work. If an
a a a alteration permit a a
of time
s required or an
+application possible District r Highway
■
■
completionUpon a
■
work, please fill out this form and forward it a
Massachusetts Department of Transportation
■ r
Arlington,ct Four
519 Appleton Street
Attentr ■ r a
r Permit
IF THIS NOTICE IS NOT RETURNED,THE LIABILITY ASSUMED UNDER THIE PEEMIT
® a
Authority Transportation ■ a r ■
Director.
ct Four Highway
I hereby notify you that the work® outlinedMassDOT Permit No. has been completed in accordance® a a
® r
requirements of MlassDOT.
th all
PermitThe Date of Compleflone.
ignedi
City/
jIU�,,��il"11 I[I III°1I„I1P1go,116, dlc ,II,1,1
II I I oll: P „ 1- n0