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Christopher Peck, DPW Director48 Wareham StreetMiddleborough, MA 02346Phone: 508-946-2481Fax: 508-946-2484
This permit must be fully completed prior to consideration.
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 (e.g. pipes, cable lines, etc.).
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, 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 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.
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
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