Fill - Free fillable Application For 100 Maple Avenue Highway Department o (SELCO) PDF form

Town of Shrewsbury

Permit Number______________

100 Maple Avenue

Date Issued_________________

Shrewsbury, MA 01545

Expiration Date______________

Highway Department

(permit is valid for 180 days from date of issue)

508-841-8513

Fees:

Fax: 508-841-8497

Trench Permit

$25.00

Highway@shrewsburyma.gov

Road Opening

$150.00

Check all that

apply

Application For

o Permit to Open, Occupy, Use and obstruct a portion of a public way

own of Shrewsbury: General bylaws of the Town Article 12 (as amended)

Pursuant to G.L.c.82A§ 1 and 520 CMR 14.00 et seq. (as amended)

ermit to open a trench on private property

Pursuant to G.L.c.82A§ 1 and 520 CMR 14.00 et seq. (as amended)

THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION

Location(s) of Excavation:

Street Address:

Phone:

Cell:

Name of Applicant:

Street Address:

City/Town State Zip

Name of Excavating Contractor: Phone: Cell:

Street Address:

City/Town State Zip Massachusetts Hoisting License #

Name of Equipment Operator: License Grade:

Street Address: Expiration Date:

City/Town State Zip

Name of Competent Person (As defined by 520 CMR 14.02): Phone: Cell:

Street Address:

City/Town State Zip

Name of Owner(s) of Property: Phone: Cell:

Street Address:

City/Town State Zip

Other Contact

Rev01 June 20

Email:

Description, location and purpose of proposed trench/boring:

Please describe the exact location of the proposed work and its purpose (include a description of what is (or is intended)

to be laid in proposed trench (eg; pipes/cable lines etc.)

Street address: _______________________________________________________________________________

Description is as follows: Starting Point:_______________________Finish Point:_________________________

Within town layout:

Size of Opening: Width:______________Depth:________________Length:______________

Number Size

Borings

On private property: Size of Opening: Width:______________Depth:________________Length:______________

For the purpose of:____________________________________________________________________________________

SPECIAL CONDITIONS:___________________________________________________________________________

Proof of Workman's Compensation:

Certificate of Insurance #:

(Certificate of Insurance and a copy of the endorsement to their insurance policy with the Town of Shrewsbury named as additional insured.)

Digsafe Confirmation # ________________________________ Start Date __________________________

Name and Contact Information of Insurer: ______________________________________________________________

Policy Expiration Date: ______________________________________

Cash Bond: Date:______________Amount:$______________(minimum $1,000)

Security Bond Issued by:______________________________________

Date:______________Amount:$______________(minimum $5,000)

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 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 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, 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 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

Rev01 June 20

CONDUCTED UNDER THIS PERMIT.

APPLICANT SIGNATURE

_____________________________________________DATE___________________________

EXCAVATOR SIGNATURE (IF DIFFERENT)

_____________________________________________DATE___________________________

OWNER'S SIGNATURE (IF DIFFERENT)

_____________________________________________DATE___________________________

For Town Use --- Do not write in this section

PERMIT APPROVED BY:

PERMITTING AUTHORITY: TOWN OF SHREWSBURY

DATE:

CONDITIONS OF APPROVAL

CONDITIONS AND REQUIREMENTS PURSUANT TO G.L.C.82A AND 520 CMR 14.00 et seq.(as amended)

1. Permits to open the road or sidewalk must be obtained at least forty-eight (48) hours before commencing of opening

excavation unless the Highway Manager has determined that an emergency situation exists

2. Flowable fill shall be required on all trenches within the traveled way or unless waived by the Highway Manager

3. All excavations commencing in the month of October must be permanently repaired by November 15

4. Once the Highway Division notifies a permit holder that the trench is in need of repair, said permit holder

has twenty-four (24) hours to repair said trench. At the end of said time the Highway Division will have the right to repair said

trench and deduct the cost of the repair from the permit holder's bond.

5. Permit holders shall give the Highway Division twenty-four (24) hours notice for inspections. If the work is not ready for inspection,

an additional fee oof $100.00 will be imposed for reinspection

6. Road closures must be approved through the Board of Selectmen at a regularly scheduled meeting.

7. Permit holders must be present at the Board of Selectmen's meeting when seeking a road closure.

Requests will include, but are not limited to suggested detour plan, Police detail, Fire notification, DPW notification,

School Dept. notification

8. The permit holder shall not open any street on Public holidays or Saturdays without the approval of the Highway Manager. If

permission is granted, the permit holder will be responsible for paying the inspector

9. A penalty permit shall be issued to any individual commencing work prior to obtaining a regular Road Opening Permit. The

fee for this permit shall increase to $1000.00

10. The permit holder shall be responsible for trench repairs for the first twelve (12) months after completion. Request by the Town

to repair a trench shall be addressed within forty-eight (48) hours

11. Winter Road Opening moritorium December 1 through March 30

12. All permit holders must follow Board of Selectmen policy 24 regarding Road Openings

By signing the application, the applicant understands and agrees to comply with the following:

i. No trench may be excavated unless the requirements of sections 40 through 40D of chapter 82, and any accompanying

regulations, have been met and this permit is invalid unless and until said requirements have been complied with by the

excavator applying for the permit including, but not limited to, the establishment of a valid excavation number with the

underground plant damage prevention system as said system is defined in section 76D of chapter 164 (DIG SAFE);

$______________Permit fee Received (yes)____(no)_____

13. Bond will only be returned if there is passing inspection and all requirements have been met. If an inspection does not take place

bond will not be returned.

Rev01 June 20

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ii.Trenches may pose a significant health and safety hazard. Pursuant to Section 1 of Chapter 82 of the General Laws, an

excavator shall not leave any open trench unattended without first making every reasonable effort to eliminate any

recognized safety hazard that may exist as a result of leaving said open trench unattended. Excavators should consult

regulations promulgated by the Department of Public Safety in order to familiarize themselves with the recognized safety

hazards associated with excavations and open trenches and the procedures required or recommended by said department

in order to make every reasonable effort to eliminate said safety hazards which may include covering, barricading or

otherwise protecting open trenches from accidental entry.

iii.Persons engaging in any trenching operation shall familiarize themselves with the federal safety standards

promulgated by the Occupational Safety and Health Administration on excavations; 29 CFR 1926.650 et.seq., entitled

Subpart P "Excavations".

iv. Excavators engaging in any trenching operation who utilize hoisting or other mechanical equipment subject to chapter

146 shall only employ individuals licensed to operate said equipment by the Department of Public Safety pursuant to

said chapter and this permit must be presented to said licensed operator before any excavation is commenced.

v. By applying for, accepting and signing this permit, the applicant hereby attests to the following: (1) that they have read

and understands the regulations promulgated by the Department of Public Safety with regard to construction related

excavations and trench safety; (2) that he has read and understands the federal safety standards promulgated by the

Occupational Safety and Health Administration on excavations: 29 CMR 1926.650 et.seq., entitled Subpart P

"Excavations" as well as any other excavation requirements established by this municipality; and (3) that he is aware of

and has, with regard to the proposed trench excavation on private property or proposed excavation of a city or town

public way that forms the basis of the permit application, complied with the requirements of sections 40-40D of chapter

82A.

vi. This permit shall be posted in plain view on the site of the trench.

For additional information please visit the Department of Public Safety's website at

www.mass.gov/dps

Summary of Excavation and Trench Safety Regulation (520 CMR 14.00 et seq.)

This summary was prepared by the Massachusetts Department of Public Safety pursuant to M.G.L.c.82A and does not include all

requirements of the 520 CMR 14.00. To view the full regulation and M.G.L.c.82A, go to www.mass.gov/dps.

Pursuant to M.G.L.c.82,§ 1, the Department of Public Safety, jointly with the Division of Occupational Safety, drafted regulations

relative to trench safety. The regulation is codified in section 14.00 of title 520 of the Code of Massachusetts Regulations. The

regulation requires all excavators to obtain a permit prior to the excavation of a trench made for a construction-related purpose on

public or private land or rights-of-way. All municipalities must establish a local permitting authority for the purpose of issuing

permits for trenches within their municipality. Trenches on land owned or controlled by a public (state) agency requires a permit to

be issued by that public agency unless otherwise designated.

In addition to the permitting requirements mandated by statute, the trench safety regulations require that all excavators,

whether public or private, take specific precautions to protect the general public and prevent unauthorized access to unattended

trenches. Accordingly, unattended trenches must be covered, barricaded or backfilled.Covers must be road plates at least 3/4" thick

or equivalent; barricades must be fences at least 6' high with no openings greater than 4" between vertical supports; backfilling

must be sufficient to eliminate the trench. Alternatively, excavators may choose to attend trenches at all times, for instance by hiring

a police detail, security guard or other attendant who will be present during times when the trench will be unattended by the

excavator.

The regulations further provide that local permitting authorities, the Department of Public Safety, or the Division of

Occupational Safety may order an immediate shutdown of a trench in the event of a death or serious injury; the failure to obtain a

permit; or the failure to implement or effectively use adequate protections for the general public. The trench shall remain shutdown

until re-inspected and authorized to re-open provided, however, that excavators shall have the right to appeal an immediate

shutdown. Permitting authorities are further authorized to suspend or revoke a permit following a hearing. Excavators may also be

subject to administrative fines issued by the Department of Public Safety for identified violations.

Summary of 1926 CFR Subpart P -OSHA Excavation Standard

This is a worker protection standard, and is designed to protect employees who are working inside a trench. This summary was

prepared by the Massachusetts Division of Occupational Safety and not OSHA for informational purposes only and does not constitute

an official interpretation by OSHA of their regulations, and may not include all aspects of the standard.

Rev01 June 20

For further information or a full copy of the standard go to www.osha.gov.

●

Trench Definition per the OSHA standard:

~ An excavation made below the surface of the ground, narrow in relation to its length.

~ In general, the depth is greater than the width, but the width of the trench is not greater than fifteen feet.

●

Protective Systems

to prevent soil wall collapse are always required in trenches deeper than 5', and are also required

in trenches less than 5' deep when the competent person determines that a hazard exists. Protection options include:

~ Shoring. Shoring must be used in accordance with the OSHA Excavation standard appendices, the equipment

manufacturer's tabulated data, or designed by a registered professional engineer.

~ Shielding.(Trench Boxes). Trench boxes must be used in accordance with the equipment manufacturer's tabulated

data, or a registered professional engineer.

~ Sloping or Benching. In Type C soils (what is most typically encountered) the excavation must extend horizontally

1 1/2 feet for every foot of trench depth on both sides, 1 foot for Type B soils, and 3/4 foot for Type A soils.

~ A registered professional engineer must design protective systems for all excavations greater than 20' in depth.

●

Ladders

must be used in trenches deeper than 4'.

~ Ladders must be inside the trench with workers at all times, and located within 25' of unobstructed lateral travel for

every worker in the trench.

~ Ladders must extend 3' above the top of the trench so workers can safely get onto and off of the ladder.

●

Inspections

of every trench worksite are required:

~ Prior to the start of each shift, and again when there is a change in conditions such as a rainstorm.

~ Inspections must be conducted by the competent person (see below).

●

Competent Person(s) is:

Capable

(i.e., trained and knowledgeable) in identifying existing and predictable hazards in the trench, and other

working conditions which may pose a hazard to workers, and

Authorized

by management to take necessary corrective action to eliminate the hazards. Employees must be

removed from hazardous areas until the hazard has been corrected.

●

Underground Utilities

must be:

~ Identified prior to opening the excavation (e.g., contact DIGSAFE).

~ Located by safe and acceptable means while excavating.

~ Protected, supported, or removed once exposed.

●

Spoils

must be kept back a minimum of 2' from the edge of the trench.

●

Surface Encumbrances

creating a hazard must be removed or supported to safeguard employees. Keep heavy

equipment and heavy material as far back from the edge of the trench as possible.

●

Stability of Adjacent Structures:

Where the stability of adjacent structures is endangered by creation of the trench, they must be underpinned, braced,

or otherwise supported.

~ Sidewalks, pavements, etc. shall not be undermined unless a support system or other method of protection is

provided.

●

Protection from water accumulation hazards:

~ It is not allowable for employees to work in trenches with accumulated water. If water control such as pumping is

used to prevent water accumulation, this must be monitored by the competent person.

~ If the trench interrupts natural drainage of surface water, ditches, dikes or other means must be used to prevent this

water from entering the excavation.

●

Additional Requirements:

~ For mobile equipment operated near the edge of a trench, a warning system such as barricades or stop logs must be

used.

~ Employees are not permitted to work underneath loads. Operators may not remain in vehicles being loaded unless

vehicles are equipped with adequate protection as per 1926.601 (b) (6).

~ Employees must wear high-visibility clothing in traffic work zones.

~ Air monitoring must be conducted in trenches deeper than 4' if the potential for a hazardous atmosphere exists. If a

hazardous atmosphere is found to exist (e.g.,O2<19.5% or >23.5%, 20% LEL, specific chemical hazard), adequate

protections shall be taken such as ventilation of the space.

~ Walkways are required where employees must cross over the trench. Walkways with guardrails must be provided for

crossing over trenches > 6' deep.

~ Employees must be protected from loose rock or soil through protections such as scaling or protective barricades.

Rev01 June 20

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