Trench PermitCITY OF NORTHAMPTON, MASSACHUSETTS PENDING APPROVAL
DEPARTMENT OF PUBLIC WORKS 95 CHESTERFIELD RD
125 locust Street
Northampton, MA 01060
413-587-1570
Fax 413-587-1576
Trench Permit Number: 2023-436
Date Approved: 4
-1 3
Expiration Date: 7 " 13
(for City Use Only)
EXCAVATION/TRENCH PERMIT
Pursuant to G.L. c. 82A and 520 CMR 14.00 et seq. (as amended)
This permit must be fully completed prior to consideration. Submit completed form with permit fee to Northampton
Department of Public Works, 125 Locust Street, Northampton, MA 01060.
This permit is issued under the provisions of M.G.L. c. 82A, 520 CMR 14.00 and applicable sections of the Revised
Ordinances of the City of Northampton, including, but not limited to, Section 285-21.
Fee: $250 Check #:6307
Date Issued:6/5/2023
Name of Applicant
Primary Phone #
JDR BUILDERS
374-7983
Street Address
Emergency Phone #
177 STATE RD
City/Town
State
Zip
Email
S. DEERFIELD
MA
01373
Name of Excavator
Primary Phone #
WALTER THAYER JR
695-8990 Richie
Street Address
Emergency Phone #
84 KING ST
City/Town
State
Zip
Email
HATFIELD
MA
01038
Name of Property Owner(s)
Primary Phone #
BECCA CONSTANTINE
695-4414
Street Address
Emergency Phone #
95 CHESTERFIELD RD
City/Town
State
Zip
Email
LEEDS
MA
01053
Insurance Certificate #
Policy Expiration Date
ON FILE
Name & Contact Information of Insurer
ON FILE
Dig Safe # & Start Date from Dig Safe Ticket:
2023-120-8700
Project Description/Location of Work. Provide the following:
® Description of purpose and exact location of proposed work including description of what is
to be laid or repaired in the proposed trench (e.g. water pipe, sewer pipe, drainpipe, gas line,
power line, communication lines, etc.)
® Sketch or drawing showing all proposed work.
®Anticipated Start of Work Date.
Description:
95 CHESTERFIELD RD
HOOK INTO WATER from City
Septic System
Electrical Conduit lines
Work on Driveway
PERMITS ASSOC. with this Trench
D13-23
W30-23
no Sewer ( septic )
Check if applicable:
❑ Emergency
® Work on Private Property
® Work in Public Right of Way
❑ Work within State Layout (attach State Permit)
❑ Work within 50' of a Public Shade Tree (see attached Public Shade Tree Regulations)
❑ Tree removal required (see attached Public Shade Tree Regulations)
❑ Tree protection, trimming, or root pruning required (see attached Public Shade Tree Regulations)
❑ Work within 100' of a wetland or 200 Ft, of a stream or river (attach Permit)
❑ Work within floodplain (attach permit)
❑ Public Water/Sewer/Drain Entry Permit (attach permit, if available)
❑ Driveway Permit (attach permit, if available)
❑ Pole and Wire Petition (attach approval)
Pg 214
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, M.G.L. c. 822, 520 CMR
14.00 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 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
for the duration of the construction.
The undersigned applicant, owner and excavator agree jointly and severally to reimburse the
municipality for any 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 signing this form, the applicant, owner and excavator acknowledge that they have read and
understand all the information set forth in and referenced within this application package and that
they agree to comply in all respects with the requirements therein.
Applicant �--�-�- - --- - � �- -- � � ---� --� I]atc
Excavator Signature (if different)
Owner Signature (if different)
-Date
Date
Pg 3A
To be completed when approved permit is picked up.
By signing below, the applicant acknowledges and agrees to all the conditions of approval stated below and
validates this permit.
Applicant
Date
For City Use -- Do not write in this section
Department Approvals/Comment
Water: 6/6/2023
Sewer/Storm Drain: 6/13/2023
FPC: 6/9/2023
Streets: 6/5/2023
Traffic Signals: 6/5/2023
❑ Subject to 5-yr. pavement moratorium Road last paved: 2018
Special Conditions: �
—
Fee
® $250 Permit Application received (Check payable to the City of Northampton)
❑ Waived. Reason:
❑Tree mitigation:
Permit Appr
�13.Z
Director of Public Works
Date
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