70 trench permit 2011 t • F M" -4'r14' -48
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OF NORTHAMPTON :
APARTMENT OF PUBLIC WORKS
123 Locust Street
Northampton,MA 01060
Phone 413-581-1570
PAX 413-587-1576
Penpit No.
ASAP 70 COUNTRY WAY, FLORENCE
6253
DISAPPROVED
Date IssueQ:-,_ .422/2011
By
(Depv[ment of Public Works)
Flo wmktC start until signed
TRENCH PERMIT
Pursuant to G L v 82A 5 I.and 520 CMR 7.00 et seq. (as amended) :
THIS PERMIT MUST BE'FULLY COMPLETED.PRtORTO CONSIDERATION
This permit(License for excavating on any public way and private properly)is issued under iht provisoasofM.G.L.c 82A S and 52Q CMR 1400
and Section 285-21ofthe Revised Ordinances of the City of Northampton subject to "Specifications for ofSUma CWd'ig ogdad adtpfd
by the Dearbnem of Public Works on Seot ber21.1 991.The applicant heathy agrees to protect as curs with bmicadeb and lights eadto swethe
City of Northampton hamdess from all claims for damages whatsoever azamg from the occupation of all propeties affected by tais permit,until such
time as the work has been approved and by the Department ofPublic Works as Ixmided;forbelow,and in the case of private utility,to pay at
charges for resurfacing. _
Fee:$250.00 Check 778 Valid for 3O days from date ofapproval.Expiration Date: 5 •
Name of Applicant
RICH ARDJAESCKE
Street Address
774 BRIDGE ROAD
City/Town STATE ZIP
NORTHAMPTON MA : 01060
Phone Cell
535-0775 RICHARD
Phone Cell
Name of Excavator(if different from applcant)
SAME
Street Address
City/Town STATE ZTP
Name of Owner(s)of Property
MITSCHICA&GABRIELLE HARTLEY
Street Address
70 COUNTRY WAY
City/Town STATE ZIP
FLORENCE 91062
Phone -Cell
Location of premised trench: 70(YICAYIXY pay, JWWiCE d
Description-and purpose of proposed trench:please describe the exact lonatipu of the proposed trench sod tivwpose.fadlude a
description of what is(Or is intended)to be laid in proposed trench(es pipestcte lines etc...)
PERCTESTNEEDED ASAP
Estimated dates of occupation of street. :ASAP
Insurance Certificate#: - ON FILE
Name and Contact Information of Insurer
ON FILE
Policy Expiration Date: '.ON FILE
Dig Safe#:. ,2011-174768
ALL PERM SSISSUED PURSUANT TO 521 CMR 14.00 SHALL.BE POSTED IN PLAIN VIEW ON THE SITE OP THE TRENCH
Note-Contractors will be charged for Inspections requested outside of regtdar working hours(7•0 a.m.-3:0Op4a,WEE)
Contractor to notify DPW when job is in progress.:
Engineers need ties to this service for our records. -
INFRA-RED SHALL BE REQUIRED AFTER TRENCH CUT IS MADE..
MOTE:
T'EhIPORARY '
PATCRREWIIRED.
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MAP 70 COUNI$YWAY, FLORENCE
i BY SIGNING THIS FORM,THE APPLICANT,OWNER,AND EXCAVATOR ACKNOWLEDGE AND CERTIFY THAT
THEY ARE EAMILJAR 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 ANYAPPLICABLE MUNICIPAL ORDINANCES,BY-LAWS AND K EGU AVOI4SAND THEYC(H'E&ANT
AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR SUCH WORK WRI.COMPLY MELEWITE IN
ALL RESPECTS AND WITH THE CONDITIONS SET FORTH BELOW.
THEONDERSIGNED OWNER AUTHORIZES Ih APPLICANT TO APPLY FOR THE PERMIT AND THE EXCAVATOR TO
UNDERTAKE SUCH WORK ONTHE PROPERTY OF THE OWNER,AND ALSO,FOWTTIE DURATION OF CONSTRUCTION,
AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPAUTTTO ENTER UPON THE PROPERTY TO MONI OR
AND INSPECT THE WORK FOR CONFORMITY WITH ITIECONDITIONS ATTACHED HERETO AND THE%AS AND
REGULATIONS GOVERNING SUCH WORK.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO REIMBURSE THE
MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSBSINCIURRED BY THE MUNICIPALITY IN CONNECTION WITH
THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,INCLUDING BUT NOT LIMITED TO ENFORCING THE
REQUIREMENTS OFSTAIE LAW ANDCONDITIONS OF THISPERMIT,INSPECHONSMADETO ASSURE COMPLIANCE
7'IIEREWITH,ANDMEASURES TAKEN RYIHEMUNICIPALITY TO PROTECT-DIE PUBLIC MIME THE APPLICANT'
OWNER OR EXCAVATOR HAS FAR PD TO COMPLY nIEREWTIH INCLUDINGPOLICE DETAI,SAND OTHER REMEDIAL
MEASURES DEEMED NECESSARY BY TTIE MUNICIPALITY.
'THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY ANDSE BAILY TO DEFEND,
INDEMNIFY,ANDHOLIIHARMLESS THE MUNICIPALITY AM)ALL OF ITS AGENTS AND EMPLOYEES FROM ANY AND
AL#,LIABII,I'I'Y,GAUbIPffi`,ONACTIRFcQ$fl ANDS PENSES RESULTINGIRIOMOR MUSING.our OF ANY INJURY,
EATH;LOSS,OR DAMAGE TO ANY PERSON ORPROPERTY DURING THE WORK CONDUCTED UNDER THISPERMCT.
APPLICANT SIGNATURE
EXCAVATOR SIGNATURE{IN.DIFPtR
OWNER'S SIGNATURE(R+DWEE