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Home My WebLink AboutHealth Permit # 10/21/2015 I TOWN OF NORTH ANDOVER Permit Number NORTH ANDOVER,MASSACHUSETTS 01845 V%ORTH Date Issued l ( � Expiration Date t aeHUS OV 10RT l00°1 R Jackie's Law — Permit Application Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant . „' r( -Phone Cell Street Address TPA O �' A p ( V6 ?Ooo 4 City/Town MA ZIP V 1, Name of Excavator(indifferent f om jaap/plicant) ° Phone J Cell Street Addres s t f C I City/Town /MA ZIP ,419 gz:./•f ol' (.0 C) /^ Name of Owners of Property Phone Cell n �, Y �. , �,.v � �. �. � �� ,�� .� ` ` `" (9 - 9.,18 (V19 9 4 Street Address yg City/Town MA ZIP c 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(eg;pipes/cable dines etc,.)Please use reverse sftle if additional space is needed. !'�l� ®/'��' �y� <�+„ypG,✓�Ci I b b'"' �Cf f � � p w�YC Insurance Certificate#: Name and Contact Information of Insurer: Policy Expiration Date: °7 Dig Safe#: 7e) Name of Competent Person(as defined by 520 CMR 7.02): Massachusetts Hoisting License# �v L, `: License Grade: :lExpiration Date: &;Z / 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. $2A,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 COVERING 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. AP I CANT/SIGN/ATiUFE r ✓� �G /`� DATE EXCAVATOR SIGNATURE(IF DIFFERENT) i DATE OWNER'S SIGNAT (IF DIFFERENT) DATE: C . 2 1 P a g e _ - _ orC 1T��vn�tse 3Do�ot;v_��e�ne�i�sect4n� _ - �?I~�R14II�7'ING �Ol'�DT�'ION�C;tT A)G'L'RQYA7�- _ 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 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. 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 lie 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 3 1 P a g e C i rc l c Insurance Fax M-M-4898 Oct Z1 2M l l lhm 1111 UL I IFICATE OF LIABILITY INSURANCE DATE(MGIIDLYYYYY) xo/21/15 THIS CERTIFICATE IS ISSUED AS A FATTER 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 13Y THE POLICIES BELOW. THIS CERf1FICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), ALffHOR1ZED REPRESE NTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT: If the Certificate holder Is an ADDITIONAL INSURED, 010 po►ICy(ies) must be endorsed. If SUBROGATION IS WAIVED,subjoct to the terms and conditions of the policy,certain policies may requiro art endorsement A statement on this Certificate dons not Confer rights to the cortificate holder in lion of such endorsem®n s, PRONCER CONTACT CYxr7l0 LaL151Y1eS$ Ins. ACfCy, Inc NAME PHONC FAH 247 Newbury Stree'k y� —bM (JAIQ No): Danver5, MA 01923 A15 kSS: „INSURB11,1I8)AFFORDII)GCOVBRAGE NAICl1 _ -- _ _. _- Ir�suRCRA;7Cxava�ors Trisuranco 25674 INSURED _ INSURER 61 Wildwood Excavation Inc, IN5URERC: 239 Holt Road rNSURERD: _ Andover, M11 01810 INSURERS _ INSU RER p: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS'rO CERTIFY THAT TI-11_POLICIES OF INSUrANC1.t'LISTED BELOW I^IAVE 13EPN ISSUED TO TI^IL INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTVVITHSTANDING ANY REQUIREMENT PERM OR CONDITION OF'ANY CONTRACT OR OTHER DOCUMENT WITH RE.$PECT TO WhUCH THIS CL"RTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICII-_S DESCRIBED HEREIN IS SUBJECT TO ALL'1'1.15 TERpn5, EXCLUSIONS AND CONDITIONS 01=SUCH POLICIES,LINIITS SHOWN MAY HAVE BEEN RL--OUCED$Y PAID CLAIMS. ILTR YYPEOFINSURANCC {I�OCSUBfiI pOL)C`�'t:)-'F POLICY NUMBER f M1DD MM100/ IIhiTS GFt14RALLIAeILITY y '6802174B50B 5/21/15 5/21/16 BACHOCCURRENCE 3 1,000, ( QQ,• X GOMhiERCtALGENERALLIADILITY CN,N1GFTOREN'rL'D °— 3Ew1ISE$-t.°_4�Sy�i[LEI�g1 ,.3001000 — GLAII916t,1ADE E0 owl R PAD FYP Wwone person} 9 5,000 -a•- I'ER80ML&ADVINJLrRY_ 16 1,000,00.0— GENERAL AGGRiWATE It 2,000,Q0� GEN'LAGGREGATE LIMrrAI'PLIES PER PRODUCTS.CON1 i P AGO 11; 2,000,0 Q Pollloy A At1TONOBIL9LIABILITY y �3�,.2175B321 61/23/15 6/23/,16 {t agC�cGrt:�INUL A.NYAUTO 90D)LY INJURY(Per person) I L OJ 250.D _ AUS O N D A X LIrSU OQ LGD ( 30MLY INJURY ncoldo'tt) $ 500,000 NON,O Nrp PROP[RrY oAlv'AOr — ruREDAUraa Auros rPOrao 1da�I) _ QO,,,000 UM13RCLLALIAR OCCUR ACH 000URRENCC N cxcr S LtAU cLAU s-r,410c AM RE CATE _$,.. _ CI7 RETENTION ;1 AND EMPLO E�RS'LABILITY Un221BB313 6/7715 6/7/16 2{ LT',^-.,r,r,��ITS ANY PR PRtGTORiPAI�'rNkW1'XECUT,\or Y I N ORICE VEA18EREXOLWED? N NIAI FP9C.KgCGDENr S 100.000 (Mynda+orvInNH) 01.DISEASHACAIMPLOYF ,;, _ 10Q,Q00 I If'aadaerlhsundor 500 000 D c'RIPTION OP OPERATIONS bolow E„L,DI3EARr-PDL(cY L IM IT CQSCRIP'nON OP OPERATIONS i LOCATIONS r VRHIOIX8 !Attach ACORD 101,Additional Rarmrks Schodtdo,it more ermoo Its rugi-i red) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED PQI.ICIGS OE CANCELLED BEFORE THC EXPIRATION DATE YW,REdF, NOTICE WILL BE DELIVERED IN Town of North AridQver ACCORDANCE WIYH THE PQLICY PROVISIONS, 1600 Osgood Street North Andover, MPS 01845 AUTNORIZCORSPRSSENZATIVS Ihaula !Rajas O 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORI3 Phone: Fax: (978) 475-2541 E-Mail: