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Home My WebLink AboutHealth Permit # 10/22/2015 e„ Z-.P ca TOWN OF NORTH ANDOVER Permit Number ..Y. NORTH ANDOVER,MASSACHUSETTS O1845 Date Issued yyb, .. ,... I, d Expiration Date S'T couS4 REcEIVED \4 HEALIH DEPPJkTMEN1' 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 17>t T-T" P t p "V–= Phone Cell 4111r6 'I 170S Street Address ' ' t-4 A(vi W=--y City/Town MA ZIP i L1_A;===f 1 Name of Excavator(if different from applicant) Phone Cell Street Address w A '=ice :3 ;— 14 City/Town MA ZIP Name of Owner(s)of Property Phone Cell VUts+-m 11 N A G--t- c (- (--)- at o coq 376 Street Address Co z 5' &3 I q 1-+ :T'/q(00 MA 01.143 City/Town MA ZIP Other Contact Permit Fee Received N Ye 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 lines etc..) Please use reverse side If additional space is needed. t�L Insurance Certificate#: Name and Contact Information of Insurer: 0,1,-,)oCmc_s, - prow Policy Expiration Date: % 7 f 7 fz i Dig Safe Name of Competent Person(as defined by 520 CMR 7,02): Massachusetts Hoisting License# License Grade: ®`'I��`✓ to Expiration Date: 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 ITVNSPECT 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 SIGNATURE - DATE EXCAV R SIG T E (IF DIFFE NT) <� DATE OWNER'S SIGNATURE(IF DIFFERENT) DATE: 21Page i - PIR1 i iPPI(t0 YED T3 PIS�,MI'I i'ING At'�T�It�I� - 1`tate - � � � Applrcatrpn�+ee - _ i 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); 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- p y P Ip� p � q '. 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 OP ID: LK DATE(MM/DDIYYYY) 10/21 CERTIFICATE OF LIABILITY INSURANCE ' /2015 THIS CERTIFICATE IS ISSUED AS A MATTER 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 BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les) must be endorsed. if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: DeSanctis Insurance Agcy,Inc. PHONE FAX 100 Unicorn Park Drive (A/C,No Ext); AIC,No E-M Woburn,MA 01801 ADDRESS: PRODUCER CUSTOMER to a:PITTP-1 INSURER(S)AFFORDING COVERAGE NAIC# INSURED Pitt Pipeline Company, Inc. INSURER A:Acadia Insurance Company 31325 25 Sullivan Road,Unit 7 INSURER B: Billerica,MA 01862 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD f 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 BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR A-DL 5UBR POL'C MM DDS LIMITS T WV, TYPE OF INSURANCE D= LTR GENERAL LIABILITY INIR POLICY NUMBER tMM11D=I1 IMMIDOM) EACH OCCURRENCE $ 1,000,000 DAMAGE TO HEN - 300,000 rA X COMMERCIAL GENERAL LIABILITY CPA010379721 01/0112015 01/01/2016 PREMISES(Eaocc,ur".ncc) $ CLAIMS-MADE 1XI OCCUR MED EXP(Any one person) $ 10,000 X XCU Coverage PERSONAL&ADV INJURY $ 1,000,000 X Contractual Liab GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: -PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY FIX-11 JPERCoi LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ A X SCHEDULED AUTOS MAA010987621 01/01/2015 01/01/2016 PROPERTY DAMAGE X HIRED AUTOS (PER ACCIDENT) _ $ X NON-OWNED AUTOS $ — F] 1 1 $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE CUA010379921 0110112015 01101/2016 -AGGREGATE $ 5,000,000 DEDUCTIBLE $ RETENTION $ — $ WORKERS COMPENSATION X I TORY STATU 'OTH- CRY LIM f S 1 I ER AND EMPLOYERS'LIABILITY Y/N N/A A ANY PROPRIETORIPARTNER/EXECUTIVE —] WCA016600319(MA,NH) 01101/2015 0110112016 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? F 1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes, a under describe I DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 D A �Limited Pollution CPA010379721 01/01/2015'— 01/01/2016 Limit $100K/$100K Ded. 250 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Project:West Mill Park* 4 High Street North Andover MA."ADDITIONAL "n&WRATER,TAAN THOSE REWIRED BY CONTRACT."The Town of INSUREDS LIMITS ARE North Andover is named as additional insured with respects to General Liability. CERTIFICATE HOLDER CANCELLATION NORTA16 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. Health Department 1600 Osgood Street, Bldg 20 AUTHORIZED REPRESENTATIVE ✓ North Andover, MA 01845 V A 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD