HomeMy WebLinkAboutHealth Permit # 11/12/2015 TOWN OF NORTH ANDOVER Permit Number
NORTH ANDOVER,MASSACHUSETTS 01845
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Expiration Date
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Jackie's Law — Permit Application 11EALTIi DEPARTMF.NT
Pursuant to G.L. e. 82A §1 and 520 CIY R 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant aelLO en fe.- r�fe r LCC Phone Celt
P �o3-76s-i�7�
Street Address
City/Town ( MA I ZIP
9� 41.1l. 6.3639-
Name of Excavator(if different from applicant) Phone Cell
Street Address
City/Town MA I ZIP
Name of Owner(s)of Property � me ( Phone Cell
Street Address
City/Town ( MA ZIP
�1/ri✓-YA tom- M C I S-W
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 lines etc..)Please use reverse side if additional space is needed.
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Insurance Certificate#:AIRP 5113 6 6
Name and Coon°tact Information of Insurer:
(.,pgr-
Policy Expiration Date:
Dig Safe#: aU/S,_. _5''0_
Name of Competent Person(as defined by 520 CMR 7.42):
lil/Y III�?A 8 Willi
Massachusetts Hoisting License#
16_ 1Q97s
License Grade: a,4 Ex iration 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.e. 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 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.
APPLICANT SIGNATURE
DATE
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
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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:
6
No trench maybe 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 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.g_ov/tins
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Summ=of Excavation and Trench Safely Regulation(520 CMR 14.00 et seal
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. 82, § 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 permitting 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.
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 back£ilied. Covers
must be road plates at least 3/a"thick or equivalent;barricades must be fences at least 6'high with no openings greater
than 4" between vertical supports; backfilling must be sufficient to eliminate the trench. Alternatively, excavators
may choose to attend trenches at all times,for instance by hiring a police detail,security guard or other attendant who
will be present during times when the trench will be unattended by the excavator.
The regulations farther provide that local permitting authorities,the Department of Public Safety,or the Division of
Occupational Safety may order an immediate shutdown of a trench in the event of a death or serious injury;the failure
to obtain a permit; or the failure to implement or effectively use adequate protections for the general public. The
trench shall remain shutdown until re-inspected and authorized to re-open provided, however,the excavators shall
have the right to appeal an immediate shutdown. 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 identified violations.
Summary of 1926 CFR Subpart P-OSHA 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 www.osha.aov.
Trench Definition per the OSHA standard:
• An excavation made below the surface of the ground,narrow in relation to its length.
• In general,the depth is greater than the width,but the width of the trench is not greater than fifteen
feet.
9 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:
• 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.
• Shielding(Trench Boxes). Trench boxes must be used in accordance with the equipment
manufacturer's tabulated data,or a registered professional engineer.
• Sloping or Benching. In Type C soils(what is most typically encountered)the excavation must
extend horizontally 1 %z feet for every foot of trench depth on both sides, I foot for Type B soils,
and 1/4 foot for Type A soils.
• A registered professional engineer must design protective systems for all excavations greater than
20'in depth.
continued
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