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1 Trench 2017 dar, 29. 2017, 1 .52PM NORTHAMPTON DPN' NH. 63P1 P, 2 FR,,.........._....• � .-.-...,..JCTO..�........ ...,. --•28/201702:50:00 g2125_ • lh :: I Jun 1 rS+. 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 / _37`1._.___-.__.._ . Ic ufApllieem Prim Phan H L" CS 3,lt to Pk 9 L yS-:Jib9 $m:ul�.ddrexsO Iut/ �r� , Ern/ ency,P7ne t�(6 nl7 4�,]idIV /5 State Zfr1 El,/3 ' 0 2- ' 7/ xplanation it Rason for request for permit extension. h p 7'1 JU (e/12 it 5, 0_5 oaf A J9i7C. 4;V --Iii P , t a .rr/ 1 1./t HC ail Projected Completion Dia: Dig Safe He____i _,y_y,,,._ w .. �q e • -Ion •- • A li 1�pture/t,(1il —.._[ Mate:; 2 b • / 7 V l ' For City Use-Dv vet write in this section Cuedltions of Apprvyal: 0 If applicable(Sec AtLLchcd) Permit Apps crY ai Director of Public Works pp.W. cs nlbMrvndt Po-1k hnusbn Refloat( ASAP ig-?±,""yo CITY OF NORTHAMPTON,MASSACHUSETTS 1 JUNIPER_. f r.� t 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. • Utiels (1,0011( 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