Permiteyes

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SECTION 1 - SITE INFORMATION

* Street Name

* Street Number

* Parcel Number

Zone

* Street Name

* Street Number

* Parcel Number

Zone

Unit Number

* SECTION 2 - OWNER INFORMATION

Same As Site Information

Owner Name

Street Number

Street Name

City

State

Zip Code

Telephone

* Email

* SECTION 3 - APPLICANT INFORMATION

Same As Owner

Applicant Name

Street Number

Street Name

City

State

Zip Code

Telephone

SECTION 4 - MAILING ADDRESS Same As

Street Number

Street Name

City

State

Zip Code

* SECTION 5 - EXCAVATOR INFORMATION Same As

Company Name

Street Number

Street Name

City

State

Zip

Telephone

* Email

SECTION 6 - OTHER INFORMATION

* Dig Safe Number

Date Valid Until

* Description, location and purpose of proposed trench

Anticipated Trench Operation * Start Date

Select date

End Date

Select date

All applicants must review the following Trench Terms and Conditions and acknowledge said regulations before proceeding with submission

* I have reviewed and agreed to the Trench application Terms and Conditions

DECLARATION

By signing this form, the applicant/excavator and owner, 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. c. 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/excavator 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 govering such work. The undersigned applicant/excavator and owner 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/excavator and owner 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.

I, as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury.

* I do hereby certify under the pains & penalties of perjury that the information provided above is true and correct.

Date

Select date

* Indicates Mandatory Field.