PERMIT FEE___________________
STREET ADDRESS________________________
CITY OF PITTSFIELD
PERMIT NUMBER_______________
DATE________________
DIGSAFE_____________________
DEPARTMENT OF PUBLIC WORKS & UTILITIES, CITY HALL, 70 ALLEN STREET, PITTSFIELD, MA 01201
413-499-9330
APPLICATION FOR TRENCH PERMIT
Pursuant to G.L. c. 82A and 520 CMR7.00 et seq. (as amended)
Name of Applicant__________________________________________ Phone_________________________ Cell___________________
Address__________________________________________________ Town _________________________ State _______ Zip________
Name of Owner ____________________________________________ Phone ________________________ Cell ___________________
Address __________________________________________________ Town ________________________ State _______ Zip ________
Contractor_________________________________________________ Phone _________________________ Cell__________________
Address __________________________________________________ Town __________________________ State ______ Zip _______
E-mail Address __________________________________________________
Describe exact location and purpose of proposed trench.
Name of Competent Person (as Defined by 520 CMR 7.02)_____________________________ Phone/ Cell ______________________
Name of Excavator Operator ______________________________________________________________________________________
Hoisting License No/ Grade/ Expiration ______________________________________________________________________________
Name of Insurance Company
Phone ______________________________
Persons engaging in any trenching operation shall familiarize themselves with the federal safety standards promulgated by the Department
of Public Safety and Health Administration on excavations: 29 CFR 1926.650 e.t.seq., entitled Subpart P Excavations.
By applying for, accepting and signing this permit, the applicant attests to the following: (i) that he has read and understood the regulations
promulgated by the Department of Public Safety with regard to trench safety; (ii) that he has read and understood the federal safety
standards promulgated by the Occupational Safety and Health Administration on excavations: 29 CFR 1926.650 e.t.seq., entitled Subpart P
Excavations.
APPLICANT SIGNATURE_________________________________________________ DATE ___________________________
CONTRACTOR SIGNATURE_______________________________________________ DATE __________________________
EXCAVATOR OPERATOR SIGNATURE______________________________________DATE __________________________
OWNER’S SIGNATURE____________________________________________________ DATE __________________________
APPROVAL______________________________________ DATE_________________ EXPIRATION ________________