TOWN OF NORTH ANDOVER DIVISION OF PUBLIC WORKS 384 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845-2909 Street Opening & Trench Excavation Permit Pursuant to Policy & Town Bylaw Chapter 161-3, (as amended) With PERFORMANCE BOND AGREEMENT AND The Commonwealth of Massachusetts, Jackie’s Law – Trench Permit Pursuant to G.L. c. 82A §1 and 520 CMR 14.00 et seq., (as amended) PRINT OR TYPE IN BLUE OR BLACK INK

Date

North Andover Permit:

Cash Bond: $

Permit Fee: N/A

DIG SAFE #:

SITE EMERGENCY CONTACT:

Applicant/Contractor:

Address

Contractor’s Phone Number:

Contractor’s Email:

City

State

NAME & PHONE #

Zip

The applicant requests permission to excavate the street/sidewalk at the following SITE LOCATION:

Main Service

On Road Off Road

For the purpose of (check only one)

SEWER

WATER

DRAIN

GAS

ELECTRIC

CONDUIT OTHER:

Address

Property Owner of Record:

City

State

Detour Permit

Approved

Zip

Telephone #

Police: This excavation will require a police detail to be hired at the contractor’s expense: Yes No Denied

Approval is based upon the following special conditions or comments: 14” COMPACTED GRAVEL

4” BIT. CONC. ASPHALT HMA

2” HMA BINDER

2” HMA MODIFIED FINISH Type I-1

1.5” Mill down & Heavy Tack Coat & Modified Finish Bituminous Concrete Asphalt Type I-1, after a winter freeze/thaw cycle.

Operations Manager DPW

Date

Inspected &Approved

Date

1

TOWN OF NORTH ANDOVER DIVISION OF PUBLIC WORKS 384 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845-2909 Street Opening & Trench Excavation Permit Pursuant to Policy & Town Bylaw Chapter 161-3, (as amended) With PERFORMANCE BOND AGREEMENT AND The Commonwealth of Massachusetts, Jackie’s Law – Trench Permit Pursuant to G.L. c. 82A §1 and 520 CMR 14.00 et seq., (as amended) PRINT OR TYPE IN BLUE OR BLACK INK

Excavator Permit Holder Information: _______________________________________________________________________________________________________ Printed Name & Address _________________________________________________________________

______________________________________________

Signature:

Telephone / Emergency Contact Number

Excavator Permit Holder Information - continued Competent Person as defined by 520CMR 7.02 Printed Name:_________________________________

Massachusetts Hoisting License #: ________________________

License Grade :________________________________

License Expiration Date: ___________________________

Name and Contact Information of Insurer of Certificate of Liability : _________________________________________________________________________________________________________ Company Name Address Telephone Insurance Certificate #: ____________________________

Policy Expiration Date: ____________________________

Name and Contact Information of $10,000 Paper Surety Bond Insurer: Insurance Company:

Bonding Co.: Bond on file Yes

Location: Bonding Number:

Expiration Date:

No

Whereas pursuant to the provisions of Chapter 161 Section 161-3 of the North Andover Town Bylaws, the grantee agrees to provide a plan and a bond in the sum of $10,000.00 bound unto the Town of North Andover and an additional refundable amount of [$ ] to assure proper performance and completion as defined in the general specifications and conditions below and as attached.

2

TOWN OF NORTH ANDOVER DIVISION OF PUBLIC WORKS 384 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845-2909 Street Opening & Trench Excavation Permit Pursuant to Policy & Town Bylaw Chapter 161-3, (as amended) With PERFORMANCE BOND AGREEMENT AND The Commonwealth of Massachusetts, Jackie’s Law – Trench Permit Pursuant to G.L. c. 82A §1 and 520 CMR 14.00 et seq., (as amended) PRINT OR TYPE IN BLUE OR BLACK INK

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, M.G.L. c.82a, 520 CMR 7.00 et seq., M.G.L. c.82, §40-40E, 220 CMR 99, 109, 111, 113, 125 & 126, D.P.U. 12-120-C 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 governing 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. The undersigned applicant/excavator and owner agree jointly and severally to comply and abide by the Town of North Andover Street Opening & Trench Excavation Policy and the General Specifications & Conditions contained therein, and acknowledge that they are fully aware of said policy and the information contained therein inclusive of pages 1-8.

I)

In witness whereof those signed below have here unto executed this agreement.

______________________________________________________ APPLICANT/CONTRACTOR SIGNATURE Date

______________________________________________________ EXCAVATOR SIGNATURE Date

______________________________________________________ PROPERTY OWNER’S SIGNATURE (IF DIFFERENT) Date

For City/Town use -- Do not write in this section PERMIT APPROVED BY ____________________________________

3 PERMITTING AUTHORITY Division of Public Works

Date_______________