1 Trench 2017 dar, 29. 2017, 1 .52PM NORTHAMPTON DPN' NH. 63P1 P, 2
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CITY OF NORTHAMPTON,MASSACIIUSE
DEPARTMENT OF PUBLIC WORKS Trench Permit Number 2DIZ-✓/�
Il thasyst StreetNo qqt)
• "T' rlhsnhptuq MA 111060 Date Approved: )_2.1 „Y� 1 ..__ -
Fr' P 413-day-1670
• Fax 413-5E74676 Revised Expiration Dale: /O`z"7-7-7
(far City Use only)
EXCAVATION/TRENCH PERMIT EXTENSION REQUEST
Pursuant to C.L.c.82A and 520 CMR 14.00 el seq.(as amended}
This permit extension request must be fully completed prior to consideration.Submit completed
be Northampton Department of Public Works, 125 Locust Street,Northampton,MA 01060.
Thispermit extension is issued under the provisions or M.G.L.c.82A,520 CMR 14.00 and applicable
sections of the Revised Ordinances of the City of Northampton,including,hut not limited to,Section 285.21.
It is subject to all the same requirements and regulations that arc required in the original permit and as
amended as conditions of this pcnnit extension.
By signing this form,the applicant acknowledges that he/rbc has read and understuads all the
informative set forth in and referenced within this nppllendon package and that they agree to comply
in all respects with the requirements therein.
Issued Trench Permitber
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xplanation it Rason for request for permit extension. h p 7'1 JU (e/12 it 5,
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Projected Completion Dia: Dig Safe He____i _,y_y,,,._
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For City Use-Dv vet write in this section
Cuedltions of Apprvyal: 0 If applicable(Sec AtLLchcd)
Permit Apps
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ai Director of Public Works
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ig-?±,""yo CITY OF NORTHAMPTON,MASSACHUSETTS 1 JUNIPER_. f
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DEPARTMENT OF PUBLIC WORKS 2017-314
r ��Ijy"'d125 Locust Street Trench Permit Number:
iy- dR Northampton,MA 01060 �/ gC -
.1670 Date Approved:o2 ) / /!'L/
-mad. Fax 413-587-1576 Expiration Date: 3-494717
_..
(for City Use Only)
EXCAVATION/TRENCH PERMIT
Pursuant to G.L.c. 82A and 520 CMR 14.00 et seq.(as amended)
This permit must be fully completed prior to consideration.Submit completed form with permit fee to
Northampton Department of Public Works, 125 Locust Street,Northampton,MA 01060.
This permit is issued under the provisions of M.G.L.c.82A,520 CMR 14.00 and applicable sections orthe
Revised Ordinances of the City of Northampton,including,but not limited to,Section 285-21.
Fee:$250 Check 4: 68331 - Date Issued: 2/21/17
Name of Applicant Primary Phone ft
KARL'S EXCAVATING/SITE WORK 413-549-5396
Street Address Emergency Phone#
327 RIVER ROAD SAME
City/Town State Zip Email
HADLEY MA 01035
Name of Excavator Primary Phone#
SAME -
Street Address Emergency Phone#
City/Town State Zip Email
Name of Property Owner(s) Primary Phone ft
CITY OF NORTHAMPTON 587-1570
Street Address Emergency Phone#
I JUMPER PLACE SAME
City/Town State Zip Email
NORTHAMPTON MA 01060
Insurance Certificate# Policy Expiration Date
ON FILE
Name&Contact Information of Insurer
ON FILE
Dig Safe
2017-070-3733
Prot Description/Location of Work.Provide the following:
Description of purpose and exact location of proposed work including description of what is to
be laid or repaired in the proposed trench(e.g. water pipe,sewer pipe, drain pipe,gas line,
�l power line, communication lines, etc
I I Sketch or drawing showing all proposed work.
ZAnticipated Start of Work Date.
1 JUNIPER
INSTALL TEST NTS
YES NO
X Check here if Emergency.
Describe.
X Work in Public Right-of-Way _
X Work on Private Property _
Work within State Layout(If yes,attach State Permit)
Work within 100 ft.of a wetland or 200 ft.of a stream or river.(If yes,attach Permit;_
Work within Floodplain.(If yes,attach Permit)
Public Water/Sewer/Drain Entry Permit(Attach Permit,if available)
Driveway Permit(Attach Permit,if available) _ '..
Pc 214
. /
By signing this form,the applicant,owner and excavator all ackno ledge and certify that
they are familiar with,or,before commencement of the work,will :ecome familiar with,all
laws and regulations applicable to work proposed,including OSHA regulations,M.G.L.c.
82a,520 CMR 14.00 et seq.,and any applicable municipal ordinanc s,by-laws and
regulations,and they covenant and agree that all work done under he permit issued for such
work will comply therewith in all respects and with the conditions s t forth below.
The undersigned owner authorizes the applicant to apply for the pe mit and authorizes
persons duly appointed by the municipality to enter upon the prope ty to monitor and
inspect the work for conformity with the conditions attached hereto and the laws and
regulations governing such work for the duration of the construcfio:.
The undersigned applicant,owner and excavator agree jointly and everally to reimburse t e
municipality for any costs and expenses incurred by the municipali s in connection with thi,
permit and the work conducted thereunder,including but not limit d to enforcing the
requirements of state law and conditions of this permit,inspections :ade to assure
compliance therewith,and measures taken by the municipality top otect the public where
the applicant,owner or excavator has failed to comply therewith,in luding police details d
other remedial measures deemed necessary by the municipality.
The undersigned applicant,owner and excavator agree jointly and everally to defend,
indemnify,and hold harmless the municipality and all of its agents nd employees from an
and all liability,causes or action,costs and expenses resulting from I r arising out of any
injury,death,loss or damage to any person or property during the ork conducted under
this permit.
By signing this form,the applicant,owner and excavator acknowle l ge that they have read
and understand all the information set forth in and referenced with-u this application
package and that they agree to comply in all respects with the requi ements therein.
•
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bits 6A- to4> 2-74 -4
Applicant / Date
xca �i a 11
xcavatm igna e(ifditte[ent) Date
Owner Signature(if different) Date
Pp 9/10
To be clm leted h n a p p_rays.d Hermit is picked n
By signing below,the applicant acknowledges and agrees to all the conditions of approval stated below
and validates this permit.
A
Date
Applicant
For Of Use—Do not write in this section
Department ApprovaslComment
Other Referenced Permits
Water ri"t - 1? _
Sewer if 9_ 7-7117--
Streets �(SS �'
-36
Condition of road:
-
Road last paved:
Conditions of Approval
❑ u Refer to Engineering for plans
Control Density Fill Required
❑ Must install clean-out(See Attached) Subject to 5-yr.pavement moratorium
Other requirements(See Attached)
Water/Sewer/Drain Entry Permit
Fee
❑ $250 Permit Application Fee received(Check payable to the City of Northampton)
Fee Waived. Reason:
Permit.yea
Date
erector of Public orks
pa as