Town Of Russell             PERMIT NUMBER___________
200 Main Street            DATE ISSUED_______________
Russell, MA 01071       EXPIRATION DATE_____________
413-862-6222
TRENCH PERMIT
Pursuant to G.L. c. 1 and 520 CMR 7.00 et.seq. (as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant					Phone		Cell
Street Address
City/Town			MA	Zip
Name of Excavator (if different from applicant)					Phone		Cell
Street Address
City/Town			MA	ZIP
Name of Owner(s) of Property					Phone		Cell
Street Address
City/Town			MA	ZIP
Other Contacts					Permit Fee Received  No (  )  Yes (  )
Description, location and purpose of proposed trench:
Please describe the exact location and 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…)  Please use
second page if additional space is needed.
Insurance Certificate #:
Name and Contact Information of Insurer:
Policy Expiration Date:
Dig safe #:
Name of Competent Person (as defined by 520 CMR 7.02):
Massachusetts Hoisting License #
License Grade:					Expiration Date:
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 THE 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
DURATION OF THE 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 TO 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.
APPLICANT SIGNATURE
____________________________________  DATE______________________
EXCAVATOR SIGNATURE
____________________________________ DATE______________________
OWNERS SIGNATURE (IF DIFFERENT)
____________________________________ DATE______________________
FOR RUSSELL OFFICIALS:  DO NOT WRITE BELOW THIS SECTION
PERMIT APPROVED BY:					APPLICATION FEE:
PERMITTING AUTHORITY:
CONDITIONS OF APPROVAL:
DATE: