43 Trench Permit 2011 PENDING APPROVAL 43 OLD WILSON ROAD
CITY OF NORTHAMPTON Permit N 6345
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DEPARTMENT OF PUBLIC WORKS PPROVED DISAPPROVED
- - 4 125 Locust Street Date Issue 6/21/2011
Northampton,MA 01060 By
Phone 413-587-1570
FAX 413-587-1576
TRENCH PERMIT
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
his permit(License for excavating on any public way and private property)is issued under the provisions of M.G.L.c 82A§ I and 520 CMR 14 00
nd Section 285-21 of the Revised Ordinances of the City of Northampton subject to the"Specifications for Care of Street Cuts"approved and adopted
y the Department of Public Works on September 21,1991_The applicant hereby agrees to protect all cuts with barricades and lights,and to save the
lity of Northampton harmless from all claims for damages whatsoever arising from the occupation of all properties affected by this permit,until such
me as the work has been approved and accepted by the Department of Public Works as provided for below,and in the case of private utility,to pay all
barges for resurfacing.
'ee'.5250.00 Check4 riQ(Oi I Valid for 30 days from date of approval.Expiration Date:
(Department of Public Works
No work to start until signed
Jame of Applicant
KARL'S SITE WORK, INC.
street Address
327 RIVER DRIVE
:ity/Town STATE ZIP
HADLEY MA 01035
Phone Cell
549-5396
dame of Excavator(if different from applicant)
SAME
street Address
:ity/Town STATE ZIP
Phone Cel
Dame of Owner(s)of Property
WILLIAM CICHANOWICZ
Street Address
43 OLD WILSON ROAD
:ity/Town STATE ZIP
NORTHAMPTON MA 01060
Phone Cell
Location of proposed trench: 43 OLD WILSON ROAD
Description 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...)
PERC TEST
Estimated dates of occupation of street: PENDING APPROVAL
Insurance Certificate N: ON FILE
Name and Contact Information of Insurer:
ON FILE
Policy Expiration Date: ON FILE
Din Safe N: 2011-240-6860
ALL PERMITS ISSUED PURSUANT TO 520 CMR 14.00 SHALL BE POSTED IN PLAIN VIEW ON THE SITE OF THE TRENCH
Note-Contractors will be charged for Inspections requested outside of regular working hours(7.00 a.m.-3:00 p.m.M-F)
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
NOTE:
TEMPORARY
PATCH REQUIRED
PENDING APPROVAL 43 OLD WILSON ROAD
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,O.L.c.82A,520 CMR
7.00 et.seq,AND ANY APPLICABLE MUNICIPAL ORDINANCES,BY-LAWS AND REGULATIONS AND THEY COVENANT
AND AGREE IHAT 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 GOVERNING 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 SI .NAIIIEF
EXCAVATOR SIGNATURE(IF DIFFERENT)
OWNERS SIGNATURE(IF DIFFERENT)
DATE / ) ) 5 I
DATE
DATE
For City/Town use--Do not write in this section
0.201. row 0
SEWER -371 (Vea // 71/0 SCkJ6/�❑
STREETS /t 6j a /i L
Control Density Fill Required
Must install clean-out(See Attached)
Refer to Engmeenng for plans
Subject to 5-year pavement moratorium
Condition of road/Road last pave
Si
City Engin