Fillable Blasting-permit-application Blasting Permit Application

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Blasting-permit-application Blasting Permit Application

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U.S.A. forms for Town of Kennebunkport

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Blasting Permit Application Town of Kennebunkport
Permit # _____________ Fee $100.00 6 Elm Street Kennebunkport, ME 04046
Phone 207)967-4243 Fax: 967-8470
Date issued ___________By_____________ www.kennebunkportme.gov
For: Map _____ Block _____ Lot _____ Zone _____ Shoreland _____ RP _____
NOTE: All data fields must be filled for application to be processed. Put N/A in any field that does not apply to this permit.
OWNER DETAILS
Name:_______________________________ __Street Address____________________________________
Mailing Address______________________________________________State_______Zip code___________
Contact phone #:______ ____________ Email address:_____________________________
Address/location of Blasting:________________________________________________________________
The Owner agrees to hold harmless and indemnify the Municipality and its employees from any claims, or action arising out of
the blasting activity subject to this permit, or any construction or installation, development of the site, inspection of the building
plans, site or building associated with said blasting, including claims based on negligence of the Municipality or its employees.
I have read, understood and agreed to the above conditions.
Signature of Owner Date
DETAILS OF ENTITY PERFORMING BLASTING
Contractor/ Company Name:__________________________________________Phone:________________
Address___________________________________________________________State_______Zip code____
License Type & Number:___________________________________________ _____Expiration:___________
License issued by:_________________________________________________________________________
Name of Person/ people who will carry out blasting:_______________________________________________
License Type & Number:_________________________________________________Expiraton: _________
Has this person had previous experience with use of explosives?____________________________________
The entity and/ or individuals performing blasting operations agree to hold harmless and indemnify the Municipality and its employees from any
claims, or action arising out of the blasting activity subject to this permit, or any construction or installation, development of the site, inspection
of the building plans, site or building associated with said blasting, including claims based on negligence of the Municipality or its employees. I
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have read, understood and agreed to the above conditions. I declare the information provided to be correct, and undertake to comply with all
relevant legislation.
Signature of Applicant/ Contractor
Date
PUBLIC RISK INSURANCE POLICY DETAILS
Name of Insurer:_______________________________________Name of Insured:______________________
Policy Number:__________________________________________Expiry date:_______ __________
Amount of Coverage— Property $________________________Bodily Injury $_________________________
BLASTING DETAILS
Dates of proposed blasting From:____________________________To:____________________________
Precise Location__________________________________________________________________________
Maximum size charge:_______________________Detonation:______________________________________
Diameter of holes:________________________________Average depth of holes:______________________
Means of storage on job site:_________________________________________________________________
Distance to nearest structure(s):________feet. Structure(s) occupied as:______________________________
Type of Cover to be used:___________________________________________________________________
Projected Cubic Yardage to be displaced:_______________cu. yd.
TERMS & CONDITIONS
1. The Blaster shall advise, in writing, all property owners of properties within 500 feet of the blasting
location, the expected date, time and duration of blasting operations, and the name, address and
telephone number of the contractor performing the blasting. Proof of certified mail notification must be
provided to the Code Enforcement Office prior to issuance of the permit. (Canada & international mail
use USPS “Certificate of Mailing”)
2. Failure of the Blasting Company to provide information concerning notification to affected properties
(within 500’) will result in revocation of the Permit.
3. The Town of Kennebunkport assumes no responsibility to the Blaster or any other person for damages
which may be caused by blasting operations carried out under this permit.
4. If blasting operations are to be carried on in the vicinity of a power line or telephone line, the Blaster must
ensure that those companies are notified of the blasting operation prior to undertaking such activity.
5. Ten (10) minutes prior to detonation the Blaster shall visually check the area for pedestrians and shall
warn them of the impending blast.
6. An alarm will be sounded one (1) minute and again at 30 seconds prior to detonation.
7. The Blaster shall promptly notify the Town Code Enforcement Office when the job is complete.
“I certify to the accuracy of the data submitted herein and any attachments hereto of this application. Any blasting operations for which this
application is made will be in accordance with the Town of Kennebunkport’s Land Use Ordinance Article 6.17 and 25 M.R.S.A. sec 2471 et seq.
and State Fire Marshal Rules, Chapter 31 and any other applicable State statutes and regulations.”
Signature of Applicant Date
ATTACH NAMES AND ADDRESSES OF PROPERTY OWNERS WITHIN 500 FEET OF BLASTING LOCATION
ON SEPARATE SHEET, AS WELL AS A MAP WITH HIGHLIGHTED PROPERTIES BEING NOTIFIED.
Please attach to this application a site plan of the proposed blasting location,
showing a radius of 500’ around the site. You may also attach a tax card with the
blasting location identified.
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Blasting-permit-application Blasting Permit Application

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Completed 13 July 2020

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