Trench Permit Application Form - City Of Pittsfield printable pdf download

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 ________________

Trench Permit Application Form - City Of Pittsfield