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Home My WebLink AboutHealth Permit # 6/17/2015 TOWN OF NORTH ANDOVER permit Number NORTH ANDOVER,MASSACHUSETTS 01845 tZORt11 Date Issued (9 O�qq VrU �g 4lVQ Expiration Date r HA.uw.xiv. tP{t cy �SSm.L °JTJ� b / .�� •Y 9 t1 I'.,.c� dx.,>� t J) Jac cie's Lave — Permit A Ic'a ion__ Pursuant to G.L. e. 82A §1 and 520 CMR 7.00 et seq.(as amended) ti THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant r J Phone Cell C�j r Street Address - - �� ` 2 � City/Town MA ZIP /V 0 Lk<r 0 V ;& 1-1(5- Name of Excavator(if different from applicant) Phone Cell Street Address City/Town MA ZIP Name of Owner(s)of Property Phone Cell Street Ap2dres-- V 641fJ ,-'( 6" ci A �`L City own MA ZIP ® C'W (1 Other Contact Permit Fee Received No Yes Description,location and purpose of proposed trench: Please describe the exact location of the proposed trench and its purpose(include a description of what is(or is intended)to be laid in proposed trench�((eeg;pipes/cable lines etc..)Please use reverse side if additional space is needed. Insurance Certificate#: ��cc oo✓'oe� Y. ��e S �- Name and Contact Information of Insurer: 'Co 6 t'.e'i S /I S J /,C-e Policy Expiration Date: Dig Safe#: Name of Competent Person(as defined by 520 CMR 7.02): Massachusetts Hoisting License# `j co�;-� License Grade: l c 4 Expiration Date: 7 `� BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT THEY ARE FAMILIAR WITH, OR, BEFORE COMMENCEMENT OF THE WORK, WILL BECOME FAMILIAR WITH, ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,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 PERMIT ISSUED FOR SUCH WORK WILL COMPLY 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 DURATION OF CONSTRUCTION,AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS GOVERING SUCH WORK. THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE MUNICIPALITY 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,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 INCLUDING 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 OR ARISING OUT OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT. APPLICANT NATURE, " t` DATE v EXCAVATOR SIGNATURE(IF DIFFERENT) s DATE OWN R'S SIGNATURE(IF DIFFERENT) J DATE.- -� 2 Page F -C = , - _ ,.=- _,<. _.- - � _ .__. ,_ 9sv; se . . ��c3twrte��Tussectaoii- �`1uR1 UT_ _A RAyi;irTY z COfi±JIl3ITI{� �31��P�RCI�A� — _ 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 may be excavated unless the requirements of sections 40 through 40D 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 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); ii. Trenches may pose a significant health and safety hazard. Pursuant to Section 1 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. 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 1926.650 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 said chapter and this permit must be presented to said licensed operator before any excavation is commenced; V. By applying for,accepting and signing 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 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 1926.650 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 public way that forms the basis of the permit application,complied with the requirements of sections 40- 40D of chapter 82A. vi. This permit shall be posted in plain view on the site of the trench. For additional information please visit the Department of Public Safety's website at www.mass,gov/dps 10/03/2014 12:20 9786833147 rr�ut ni�nl ACORd CERTIFICATE F LIABILITY INSURANCE 10/3120baTE(MMJOD/Y7,4 4 FTHIS CERTIFICATE 1:3 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO PjaNTS UP—ON THE CERTIFICATE HOLDER.THIS C-ERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, ErMND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSnTUTE A CONTRACT BETWEEN THE ISSUING INSURER(5), AUTHORIZED R€PRP$ENTATNE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certlflCBte tlok*is an ADDITIONAL INSURED,the poticytim)crypt be endorsed. If SUBROOATION IS WAIVED,subject to dta terms and conditk)ns of the PWICY,Cbrlaln pollcles MaY require an endomment. A SWemmrit on this CB OBUto dOES not Confer qhb to the certlflcaw hostler In lieu of wAch andersamengs). PROPRlCER M P ROBERTS INS AGCY INC (978)683-807 7.osa osg0taa Stre®t a�L ; au1a.@ rOberts3asT�zaa�o 1682--S147 North Andover, MA, 01,845 urtFtual AnFoFMG CaVERArrE C+ / INSURER A;UNDER>N1R MAS AT LLOYDS SU INRED PETER $ EXCAVATING, INC. A/a INSURER D;gtti=1" INSVRAU" CO TIMVI,5 & TIM CONSTRUCTION INSURERC;ASSOCIA' &D MPLOTERS INS CO 770 73L7XrORD STREET INsuRSR b,P=GRE18SiVI3 INSURMCE NORTH ANDOVER, MA 0184B INSURER E 978-687-,7774 INSU RF: COVERAGES CERTIFICATE NUMBER; REVISION NUMBER: THIS 13 TO C1;R71FY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR 7KE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED 6Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TEFWS, EXCLU$IONS AND COMD)TIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, N75R TYPE-OF INSURANCE POLICY NUMaER lY i(AbL F LIMITS X Co0AW L GgMERsL LtASILrtr EACH OCCURRENCE S 1 d0® 000 OIAIAIYMAb? �X QccuR PREM,SES Is occurth_ s 50 000 LGLI022141 02/19!14 02/19/15 MEDE*A, gnupewn) $ 5 000 A PERSONAL&AOvINJURY $ 1,000,000 GENL AGGREGATE UlAIT APPLIES PER; GENERAL AGGREGATE Is 2,000,000 X FOucy7JECT ❑LOO PRODUCTS-COMPIOPAGG S 1,000,000 OTHER: S AUTOtulQ91LE LIABILITY Ee owdenNO S :L'00O 000 ANYAUTO BODILY INJURY(Por Person) S ALL OWNED SCHEDULED PGCOOOO1007123 11/72/1311/22/14 13 AUTOS x AUTOS BODILY INJURY(Par abcldenl) S X HIREOAU7DS 3[. M110-0gWh�O Per aeeldbnt S S UMBRELLA L.lAe OCCUR >=AcH accuf2REN( t EXCESS LM CLAIMS MADE AGGREGATE $ DED RETENTION WOAKERS COMPENS LNN $ AND EMPLOYERS UADIL.Iry $ STATUTE ER C O�tC "MUD MW Y�NIA 7wcC510051010437210113A 11f13/13 11J13J14 EL EACHACCIDENT S 500 000 (ldMdtlaY N NH) Ifyyge3s,drxlalpeunEA.r E.L DISEASE.6A EMPLOYE S B00,000 bESERIPTION OF OPERATION$below E.L DISEASE•POLICY LIMIT 3 —500,000 D RCIAL AUTO 04461952-4 12/06/13 12/06/14 LI; $1,000,000 )ESCRIPTION OF QPERATION!,r LOCATIONS r VEHICLES (ACORD 101,Additlons)Remarks Sdx,dule,may by sttaaW H more spetc Is required) 'AX: 978-689-87.30 '0W OF NORTH A=VER =S LISTED AS AN ADD7:TIONAL INSM= IN RESMCT$ TO G]rMRA.L ,1ASXL1TY COVEXVoT. %ERTIFICATE HOLDER CAidGELLATION TOWN Op NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 384 OSC'sOOD STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH MOVER MIL 01845 ACCORDANCE WITH THE POLICY PROVISIONS. aUTHQRtZED REPRESENT T tMll I 0 LOW-2414 ACCRD CORFORATION. AlI NI'lta r owed. WRD25(2014101) The ACORD name and logo are mg isterad marks Of ACORD