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BLD-23-002067
p0 11ILI7/ e- Of & TWO FAMILY ONLY- BUILDING PERMIT ..:�=--- e, Town of Yarmouth Building Department of' y ,r, ,± , 1146 Route 28, South Yarmouth,MA 02664-4492 �- 508-398-2231 ext. 1261 Fax 508-398-0836 :,,. ' Massachusetts State Building Code,780 CMR. ,:; ermit Application To Construct, Repair, Renovate Or Demolish = :2-, �--- "` a One-or Two-Family Dwelling `- This Section For Official Use 0 Building Permit Number: (-,D.a 3-DOA 0(0 j Date Appli i - Seat 5 — 13,43'd.k. Building Official(Print Name) - Si ature Date SECTION 1:SITE INFORMATION • Li Prop sty Ad ress: 1.2 Assessors Map&Parcel Numbers / r theta A Jc 1 1'. pirtmo243t if 33 1.1 a Is this an accepted street?yes )0 no Map Number Parcel Number 1.3 Zoning Informatio 1.4 Property Di ensions: - Zs Resioe.,r,�-�I 6,.. a 1 3,y 9 t 510 -- s�'C Zoning District Proposed Use it y Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Private 0 Zone: Outside Flood Zone? Check if yes❑ Municipal 0 On site disposal system SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Rec rd: 6eo e. nicn.woof /ale-rh ewu MI, ole-iiti Name(Prin City,State,ZIP / £ 9 Ave Tice Deu't'-e 9'7t-r7L' 3363 SK/PNRPID�d No.and Street CaVI GIST•/�It?T Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction it Existing Building Cl Owner-Occupied 0 I Repairs(s) 0 l Alteration(s) 0 I Addition 0 Demolition Accessory Bldg. 0 Number of Units 1 Other 0 Specify: Brief Description of Proplose4 Work2: a vh r.) 5"A/S T/N CO T/ are AJe tt) /140 d /r°-r�. a c�e `� Co), sly-?lr Cr SECTION 4:ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: (Labor and Materials) Official Use Only 1.Building $ .s 3 6,00 vu I. Building Permit Fee:$V 01() Indicate how fee is determined: I 2.Electrical $ /Q� o o QMStandard City/Town Application Fee 3.Plumbing $ ❑Total Project Cost3(Item 6 x multiplier x /yi,O v O, d G 2. Other Fees: $ (i -#I c s.p 4.Mechanical (HVAC) $ /g oUU, U O List: 1 � pp 5.Mechanical (Fire • c_V \V- Suppression) $ 2 6-0 O , O O Total All Fees:$ • 6.Total Project Cost: $ Check No. Check Amount Cash 5 ,�/ 0 Paid in Full gl Outstanding Balance D e: 1 )Cl SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Jo h vi ' �M,i N ®Z 3 !D/3/ 23 Name of CSL older License Nummberber ExpirationDate '7 C m L,` 1>iz List CSL Type(see below) u Na.and Street tt// �A Type Description i V l llC /'l A • O Z 3 t�- 0 Unrestricted(Buildings up to 35,000 Cu.ft.) City/Town,State,ZIP R I Restricted leaFamily Dwelling M Masonry • RC I Roofing Covering WS Window and Siding S 08 ?8�' S^6 ��h Q SF Solid Fuel Burning Appliances Telephone / I tto-Mo,Dhemes. I Insulation Email address D I Demolition 5.2 Registered Home Improvement Contractor(HIC) cswt t r!f �eVe I a ID ul eo r C T/2WS r l 7 3 6 9.6, <x/'/oL a HIC Co r any Name HIC'Registrant Name HIC Registration Number Expira 'on Date ciao, P Ng.an treet/ A P 3 M ` eeet11 //"CA.4 L3 7 ,5a'8 7S 7 i3 2.- Email address City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(1M.G.L.c.152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes No 0 . SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize e20— /t4o (04 e S LL C to act on my behalf,in all matters relative to work authorized by this building permit application. 5e 147TFC 513 Prim Owner's Name(Electronic Signature) �z ate SECTION 7b:OWNER1 OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true d ac ate the best of my knowledge and understanding Jo Lin Ste., 913 2..-2.- Print Owner's or Authorized Agent's N e(Electronic Signature) Date NOTES: 1• An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.rnass.zov/d s 2. When substantial work is planned,_provide the information below: Total floor area(sg.ft.)- -L�O� ,s� Grossotalliving a(sq.ft.) /,,_. ..___S S (including garage,finished basement/attics,decks or porch) Number of fireplacesHabitable room count 1(e Number of bathrooms Number of bedrooms _ 3 Number of half/baths Type of heating system f/baths 2. Type of cooling system Number of decks/porches 2 Enclosed / Open Q 3. "Total Project Square Footage"may be substituted for"Total Project Cost" � s ■■ Pro-Mod Homes 12 Robin Lane Pocasset, MA 02559 Permitting Authorization In Massachusetts,the 365 cities and towns each have their own procedure for permitting.The permitting process often includes obtaining approvals from various town boards,such as the Board of Health,the Zoning Board of Appeals,the Conservation Commission,the Fire Department,the Historical Commission and the Highway Department.This list of approvals is not exhaustive, but is meant as an example of requirements necessary for your community during the permitting process. Because the permitting process has so many variables, neither the cost nor the time frame for obtaining the necessary permits and approvals can be generalized. For this reason, billing for permitting services will be based on time and materials,with the cost of third-party professionals(e.g.engineers, surveyors, legal,etc.) itemized separately. PRO-MOD HOMES, LLC will discuss with you the details of permitting for your project. If you have any remaining questions, however, please feel free to call our office for further clarification. This form authorizes PRO-MOD HOMES, LLC and its agents to procure the necessary building permit. This authority may include signing forms and appeals before various boards as your agent. Please sign below to indicate that you understand and agree with this authorization. Please sign your name(s)as it(they)appears on the property tax bill and deed. If more than two signatures are required, sign be on the lines provided. Date: 0/z5/2/ H eowner Ho a ner Please do not sign below unless you intend to obtain all permits yourself: Declination of Permitting Authorization I do not wish for PRO-MOD HOMES, LLC to act as my agent in the permitting process for this project. I take full responsibility for obtaining all necessary permits for the project. Date: Homeowner Homeowner ICON „ LEGACY ,; CUSTOM MODULAR HOMES ttc May 13,2021 To: Building Inspector in the Commonwealth of MA Re: Letter of Certification in accordance with The State Board of Building Regulations and Standards—The Massachusetts State Building Code-780 CMR 110.R3.5.1.1 and all specialized codes-Licensed Construction Supervisors and Certified Installers To Whom It May Concern: This letter is to certify that Brunelle Modular Erectors Corp/Jonathan Brunelle("Brunelle"),an independent contractor,is experienced in the installation of Icon Legacy Custom Modular Homes, LLC("ILCMH") manufactured modular units,and has registered with ILCMH. ILCMH has provided Brunelle with the required processes related to the installation of ILCMH manufactured modular units. Brunelle is responsible for and required to perform all installation procedures in accordance with the current approved ILCMH Set and Installation Manual, including but not limited to, lifting and installation procedures of the manufactured modular units,and required fastening and anchoring of the manufactured modular units,to assure the safe and proper placement and connection of the manufactured modular units to the field installed foundation. This letter shall remain in effect for one(1)year from the date of issuance unless terminated in writing by either party(Brunelle or ILCMH). Brunelle is responsible to provide information regarding any change in the status of their liability insurance. Termination of said liability insurance for any reason shall make this letter invalid. Sincerely, //1 1 (9/ l Bruce Bingaman Sales Manager ICON Legacy Custom Modular Homes,LLC 246 Sand Hill Road I Phone 57o-374-328o Fax 570-374-1122 iconlegacy.com Selinsgrove,PA 17870 SUBCONTRACTOR AGREEMENT Contractor: Icon Legacy Custom Modular Homes,LLC,246 Sand Hill Road,Selinsgrove,PA 17870("Icon") Subcontractor: („{Lk_i fi i . 4of (ock.Fixthretop31 Kl i l 1 i aeta. I vo( f ltit/� z)•t t fit ©� Contractor desires to hire Subcontractor to perform certain work relating to the installation of the modules manufactured by Icon,known as Icon Senal Number 1 Order Number 10359("SN# 1ON#10359"or the"Project"),for PRO-MOD HOMES,LLC.(the"Independent Builder"),as specified in 1.a.Subcontractor's Scope of Services in this Agreement("Work"),and Subcontractor desires to perform said Work at the price and upon the terms and conditions hereinafter expressed: The Contractor will provide copies of SN# /ON#10359's(i)Independent Third Party Agency approved plans("Approved Plans"),a copy of which is sent to the Independent Builder,and(ii)a copy of the as-built plans,as ordered,from Icon,by the Independent Builder(the"As-Built Plans"),a copy is shipped with the modules,to the Subcontractor.The Approved Plans and the As-Built Plans(together the"Plans")both are available(I)at the site, where the Project Is being erected,from the Independent Builder,(ii)at the Contractors place of business,And(iii)the Contractor will provide copies Of the Plans And the Contractor's Installation Manual(the"Set Manual"),to the Subcontractor via email,US Postal Service or by courier service.The Plans and i are made a part of this Subcontract Agreement insofar as they apply. The Subcontractor represents that it has(i)read this Subcontract Agreement,(ii)examined the Plans and the Set Manual and fully and completely understands them,and(iii)the Subcontractor's on site representative who will supervise the Work has examined the Plans and Set Manual and fully and completely understands them,or(iv)that both the Subcontractor and it's on-site representative who will supervise the Work have both had the full and complete opportunity to do so; In consideration of the mutual agreements herein,the Parties contract,covenant and agree as follows: 1. Subcontractor's Scope of Services. a. Subcontractor shall provide the following erection and installation of the modules as specified in the Plans and the Set Manual;(i)place modules on the independent Builder provided foundation using the crane or roll-on method,(Ii)bolt the modules together,(iii) permanently attach and affix the modules to the foundation,(iv)level floors,and(v)install independent Builder supplied lolly columns as per the Plans,(vi)align end wails and roof to each other,(vi)perform all other services normally completed by the Set Crew,(viii) perform all other services agreed upon,and(ix)protect the modules from weather related damage at all times during the performance of the Work,being sure to make the modules weather tight upon completion of the Work.The Work is to be competed to the full satisfaction of the Contractor and the Independent Builder.Subcontractor shall perform all Work and shall furnish all supervision,labor,materials, scaffolding,tools,equipment,supplies and other things necessary for the construction and completion of the Work as described in 1.a.of this Subcontract Agreement and to the satisfaction of the Contractor and Independent Builder. (NOTE;There may be some variation in the Approved Plans and the As-Built Plans.Refer to the Plans regarding the placement of foundation supports and all connections,which connections shall include,but shall not be limited to,rafter connections, module to module(box to box)connections,story to story connections,and all other connections,special or otherwise,shown on the Plans.] b. With respect to the Work covered by this Subcontract Agreement,and-except as expressly modified herein,Subcontractor shall have all rights which Contractor has,and Subcontractor shall assume all obligations,risks and responsibilities which Contractor has assumed towards the Independent Builder,and third parties as applicable,and Subcontractor shall be bound to Contractor in the same manner and to the same extent that Contractor is bound to Independent Builder or said third parties. 2. Payment. a. Contractor shall pay Subcontractor for the performance of the Work described herein,subject to any additions and deductions as agreed upon in writing,the amount of 6000 dollars($6000.00),the quoted agreed upon amount,within three(3)business days of Contractor receiving full payment from Independent Builder for satisfactory completion of the Work,providing all applicable paperwork has been submitted to Contractor.Both Contractor and independent Bulkier must agree upon the satisfactory completion of the Work. Subcontractor accepts sole and exclusive liability for all taxes and contributions required of the Subcontractor by federal,state or local laws or regulations,including,without limitation,the Federal Social Security Act and the Unemployment Compensation Law or similar laws in any state with respect to the employees of the subcontractor and the performance of the Work. 3. Subcontractor's Liability. Subcontractor shall be liable to Contractor for all costs Contractor incurs as a result of any failure of Subcontractor.Subcontractor hereby assumes the entire responsibility and liability for all work,supervision,labor and materials provided hereunder,whether or not erected in place,and for all tools,equipment,supplies and other things provided by Subcontractor until final acceptance,by the Independent Builder,of the entirety of the Work performed by the Subcontractor.In the event of any loss,damage or destruction thereof from any cause,Subcontractor shall be liable therefor,and shall repair,rebuild and make good said loss,damage or destruction at Subcontractor's cost,subject only to the extent that any net proceeds are payable under any insurance including,but shall not be limited to,property,risk, liability or other,that may be maintained by Independent Bader or Contractor. a. To the fullest extent permitted by law,Subcontractor shall indemnify,defend and hold harmless the Contractor,and it's respective officers,directors,employees and agents("Indemnified Parties")from and against all claims.damages.demands.losses,expenses, fines,causes of action,suits or other liabilities,(including all costs reasonable attorneys'fees,consequential damages,and punitive damages),arising out of or resulting from,or alleged to arise out of or arise from,the performance of Subcontractor's Work under this Subcontract Agreement,whether such claim,damage,demand,loss or expense Is attributable to bodily injury,personal injury,sickness, disease or death,or injury to or destruction of tangible property,including the loss of use resulting therefrom;but only to the extent attributable to the negligence of the Subcontractor or any entity for which it is legally responsible or vicariously liable;regardless of whether the claim is presented by an employee of Subcontractor.Such indemnity obligations shall not be in derogation or limitation of any other obligation or liability of the Subcontractor or the rights of the Contractor contained in this Subcontract Agreement or otherwise. This indemnification shall not be limited in any way by any limitation on the amount or type of damages,compensation or benefits payable by or for the Subcontractor under any workers'compensation acts,disability benefits acts or other employee benefits acts and includes any loss or injury suffered by an employee of the subcontractor.This indemnification shall survive the completion of the Work or the termination of the Subcontract Agreement DISCLAIMER:ICON LEGACY CUSTOM MODULAR HOMES,LLC PROHIBITS ALTERATIONS TO THIS DOCUMENT AND ACCEPTS NO LIABILITY OR RESPONSIBILITY FOR ALTERATIONS MADE TO THIS DOCUMENT BY OTHERS. Su6contradorAgreernent-Page 1 i ti Fi b. Subcontractor's assumption of liability is independent from,and not limited in any manner by,Subcontractor's insurance coverage obtained pursuant to Paragraph 4,or otherwise. 4. Subcontractor's Insurance. Prior to commencing the Work,Subcontractor shalt procure,and thereafter maintain,at its own expense,until final acceptance of the Work or later as required by the terms of the Subcontract Agreement,insurance coverage.At a minimum,the types of insurance and minimum policy limits specified in Exhibit"A".shall be maintained in a form and from insurers acceptable to Contractor.All insurers shall have at least an A- (excellent)rating by A.M.Best and be qualified to do business in the jurisdiction where the Project is located. Subcontractor and Contractor shall each carry its own Workers'Compensation Insurance. 5. Time of Performance. Subcontractor will coordinate its Work with the work of the Contractor,other subcontractors,and Independent Builder,so no delays or interference will occur in the completion of any part or all of the Project.Subcontractor will commence Work when directed by Contractor,or Independent Builder,and Subcontractor will proceed with the Work in a prompt and diligent manner. TIME IS OF THE ESSENCE. 6. Change ja Service. No amendment,modification,revision or other change to the scope of services hereunder,and any resultant change to compensation,must be set forth and agreed upon in writing and signed by Subcontractor and Contractor. 7. Assignment Subcontractor shall not subcontract any portion of the Work or the Subcontract Agreement and shall not assign or transfer this Subcontract Agreement,without the prior written consent of Contractor. 8. Safety. Contractor makes no representations with respect to the physical conditions or safety of the Project site.Contractor assumes no liabilities related to the Project site.The project site is owned by the Independent Buiider,the Independent Builder's customers,or others. a. Subcontractor shall,at its own expense,take all reasonable safety precautions in the performance of the Work to preserve and protect from injury Its employees engaged in the performance of the Work and all property and persons which may be affected by its operations in performing the Work.At a minimum,the Subcontractor will comply with ail applicable federal,state,and local laws,codes,rules, regulations,statues,ordinances,and requirements pertaining to the performance of the Work including the Federal Occupational Safety and Health Act("OSHA"). Subcontractor shall indemnify,defend and hold harmless Contractor and Independent Builder,and their respective officers,directors, agents and employees from and against any and all loss,which shall include,but shall riot be limited to,loss of life and/or property,or any and all liability which shall include,but shall not be limited to,attorney fees,costs,fines and penalties,arising out of or related to Subcontractors failure to comply with the terms of this provision.Subcontractor agrees that all equipment brought onto the Project Site meets the applicable safety guidelines required by OSHA,and must be licensed and have a current inspection when applicable.Further, that all persons operating equipment have been trained through a program that meets minimum OSHA requirements. Under no circumstances will Contractor or Independent Builder release Subcontractor of responsibilities,concerning safety issues on the job site. b. Subcontractor shall take all reasonable precautions for the safety of,and shall provide all reasonable protection to prevent damage,injury or loss to all property on the Project Site,caused by Subcontractor.Any damage or loss of property caused in whole or in part by Subcontractor and/or Subcontractor's subcontractor(s),or their respective employees,shall be remedied without delay. 9. Certification.License and Registration. Subcontractor warrants that it has obtained all Certifications,Licenses,Permits and Registrations to,perform contracted Work in the State and Local Jurisdiction of performance and that said Certifications,Licenses,Permits and/or Registrations remain in good standing with the State and Local Jurisdiction in which the contracted Work is being performed. 10. Governing Law. This Subcontract Agreement shall be governed by and construed in accordance with the laws of the State of Pennsylvania without regard to conflict of law principals. 11. JURY TRIAL WAIVER. EACH OF THE PARTIES DOES HEREBY KNOWINGLY,VOLUNTARILY AND INTENTIONALLY WAIVE ITS RIGHT TO A TRIAL BY JURY IN RESPECT OF ANY LITIGATION BASED HEREON,OR ARIING OUT OF,UNDER OR IN CONNECTION WITH,THIS AGREEMENT,OR ANY COURSE OF CONDUCT,DEALINGS,STATEMENTS,OR ACTIONS OF ANY PARTY ARISING OUT OF OR RELATED IN ANY MANNER TO THIS AGREEMENT. 12. Presumption Arising from Authorship. Both Parties have had the opportunity to review this Subcontract Agreement with counsel and negotiate before signing this Subcontract Agreement Therefore,there will be no presumption for or against either of the Parties arising out of the drafting of the Subcontract Agreement 13. Waiver. The failure of either party to enforce,at any time,any provision of this Subcontract Agreement shall not constitute a waiver of such provision in any way or the right of such party at any time to avail itself of such remedies as it may have for any breaches of such provision. 14. Entire Agreement This Subcontract Agreement,including all Exhibits hereto,and other documents and plans referenced,contains ail the terms agreed to by the Parties related to this subject matter.It replaces all previous discussions,understandings,and agreements. DISCLAIMER:ICON LEGACY CUSTOM MODULAR HOMES,LLC PROHIBITS ALTERATIONS TO THIS DOCUMENT AND ACCEPTS NO LIABILITY OR RESPONSIBILITY FOR ALTERATIONS MADE TO THiS DOCUMENT BY OTHERS. Subconinactor Agreement-Page 2 , IN WITNESS WHEREOF,the Parties,by their duly authorized representatives,have hereunto executed this Subcontract,on the day and year first above written. EXIBITS: A-Insurance Provisions WITNESS SUBCONTRACTOR 46A/..-.4tA‘lAUX5*-- BY 911" PRINT NAME PRINT NAME a .Z1. z02.4 QAvn . DATE TITLE Jo✓i au/tuck/ +-. C,t4 EMAIL /-14. 5-24, Octri PHONE WITNESS CONTRACTOR:Icon Legacy Custom Modular Homes,LLC BY PRINT NAME PRINT NAME DATE TITLE DISCLAIMER:ICON LEGACY CUSTOM MODULAR HOMES,LLC PROHIBITS ALTERATIONS TO THIS DOCUMENT AND ACCEPTS NO LIABILITY OR RESPONSIBILITY FOR ALTERATIONS MADE TO THIS DOCUMENT BY OTHERS. sabarnhecfo s Agreement-Page 3 — _ — _....,, . 4 ‘ • ;1111111r www.Bumellefficroular-unn Et*licensed&Insured ... ,......-.-.--,-----o--------------"""—. _-- .-, r ,...........1.-1.4.,' . . 1.- '.tsi 7.'' -ai!b: -.....•,..- 1,.• .: . . Ili:;•71/..i."•Ct..tg.-. Cnit • .a• ‘... . •*3..... .... W * '"..14.w.ew= , _ 0.' k.1 ., .".e. . SI ....% .....1. 74 ril C3 -41' CA bro. „...3-- - -.z- 4 '_.,1 .. 4.--= • = IN t i 2 --.. ---.--,-_- - 2V ar „ Ill _,.4 - - rs re.-d- -k ,-.--,- , -...." . • . .,. , • ......,,, ... •• bani ACHUSETTS COMIERCIAL = DRIVER'S UCENSE :';:r.: . .:. _. • - . '4 M S56427798 . . - - - - 1--i-4 . 19 05-17-1961 . _ _,----,.. : ss sor ta Witt-SOS .. 2---- .'. • --- ' i,- •" '-, - (-4- ,-, - - •1... LE =1.--...-.-.-• _ . a 3/MO STIMET FALL RIVER;MA 02721-4701 1106,2514 Rav17452009 4.1t—Or."#64 ., •• _ .. _ . .... 44 MZ4CITOSETT S DRIVER'S LICENSE --. -r- .-:-2. -1F4AS.L4dAssist '-4-_,, = : 41.::•••••• ..' oe 1Tig _S98711:616 3-- tz. . -.. .-- ,..-,, i i-..... - ' '''- --.5 ,:1--- -W. --. _ 'flix-113....s;. -. A . - • •..- ...- . ,.....,-. ,. t711AN M ..-":- . FALL RIVER.MA orataof ti. ' ''-• ' /...44.: e„.„.... ,„,,,,„ 5 OD LIA11.201$11kr•DIADADO .11V A a'® CERTIFICATE OF LIABILITY INSURANCE °A'�/11/20'""'"' 02/11/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CCW T Laura Turchetta NMECross Insurance,Inc.-RI PHONE (401)431-9200FAX 376 Newport Avenue ((��(C�����°�►, I�,No: (401)431-9201 ADDRESS: laura.turchetta©crossagencycom P.O.Box 4830 INSURERS)AFFORDING COVERAGE NAIC A East Providence RI 02916 iNSuRERA: Motorist Commercial Mutual Ins.Co. 13331 ENSURED INSURER B: Beacon Mutual 24017 Brunelle Modular Erectors Corp INSURER C: 500 Wilbur Ave INSURER D: INSURER E: Swansea MA 02777-2421 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2221186335 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1LTR 8R TYPE OF INSURANCE INS MD POLICY NUMBER (MPOLICY EFF POLICY EXP MIDWYYYY) (11WDD/YYTY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS MADE ®OCCUR DAMAGbTO RENTED 100000 PREMISES(Ea occurrence) $ , — MED EXP Wry one person) $ 5,000 A — 5000036967 02/13/2022 02/13/2023 PERSONAL BADVINJURY $ 1,000,000 GENT_AGGREGATE LIMITAPPLIESPER: GENERAL AGGREGATE $ 2,000,000 —1 POLICY I I JEC PROT I i n LOC PRODUCTS-COMP/OPAGG $ 2'CM°A° OTHER: $ AUTOMOBILE LIABILITY BINEEDDSINGLE LIMIT $ 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ A OWNED --SCHEDULED 5000086967 02/13/2022 02/13/2023 BODILY INJURY(Per aaddent) $ AUTOS ONLY AUTOS HIRED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS UAB CLAIMS-MADE 5000138021 02/13/2022 02/13/2023 AGGREGATE $ 1,000,000 DED RETENTION$ $ WORKERS COMPENSATION OTH- AND EMPLOYERS'LIABILITY YIN PER STATUTE ER B OFFICER/MEMBER PROPRIETOR/PARTNER/EXECUTIVE EXCLUDED? Ci�i� N/A 64768 11/02/2021 11/02/2022 E.L.EACH ACCIDENT $ �.000 {Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under � DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,0 A Leased/REnted Equipment 5000036967 02/13/2022 02/13/2023 Limit $200,000 Deductible $2,500 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached B more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ICON Legacy Custom Modular Homes,LLC ACCORDANCE WITH THE POLICY PROVISIONS. 246 Sand Hill Rd AUTHORIZED REPRESENTATIVE Selinsgrove PA 17870 4:601 gobWmaraloPP. I 01988-2015 ACORD CORPORATION. All rights ACORD 25(2018/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts ; t Department of Industrial Accidents = �l= 1 Congress Street,Suite 100 r � Boston,MA 02114-2017 �.:< www.mass.gov/dia • Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A iicant Information Please Print Le4ibi Name (Business/Organization/Individual): PiZO-/i(V P Ai es Li-C Address: /P o b/n "me City/State/Zip: Po C 025T Phone#: g"I - 3G© -fi�DG Are you an employer?Check the appropriate box: Type of project(required): 1.0 1 am a employer with employees(full and/or part-time).* New 2.Q I am a sole proprietor or partnership and have no employees working for me in 7. 2( Rem construction • any capacity.[No workers'comp.insurance required.] 8. ❑ emodeling 3.Q 1 am a homeowner doing all work myself.(No workers'comp.insurance required.]t 9. Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sole l l•El repairs or additions proprietors with no employees. 5./%'I am a general contractor and I have hired the sub-contractors listed on the attached sheet 12'❑plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.t 13.0 Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per iMIGL c. 14•Q Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number, I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: L./14 Zn S C B 2 P Policy#or Self-ins.Lic.#: ti/r' 53/r t Z 0 ?70 D // Expiration Date: id/Z•Z./gyp L Z Job Site Address: S e g. 7 Attach a copy of the workers' compensation policy declaration page(showingCitthe policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00) and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the D1A for insurance coverage verification. I do hereby certify tender the p((a��ins and penalties of perjury that the information provided above is true and correct: Signature: Phone#: S-v f S6 Z Date: Official use only. Do not write in this area,to be completed by city or town offieiaL City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 02/08/2022 /ICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS t. ATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELO . THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Diane Lima-Ferreira PARTNERS INSURANCE GROUP LLC AmPHONE.Ext)_ (508)491-3663 (FA/C.No►: ADDRESS: dferreira@partnersinsgrpllc.com 73 ALDEN RD INSURER(S)AFFORDING COVERAGE NAIC# FAIRHAVEN MA 02719 INSURER A: LM INS CORP 33600 INSURED INSURER B: PROMOD HOMES LLC INSURERC: INSURER D: 12 ROBIN LANE INSURERE: POCASSET MA 02559 INSURER F: COVERAGES CERTIFICATE NUMBER: 742984 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POUCY EFF POUCY EXP LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY► UMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL BADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ (Ea accident) — ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED _ AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE _ HIRED AUTOS _ AUTOS (Per accident) $ $ UMBRELLA UAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE EOTH- R AND EMPLOYERS'UABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A WC531S620270011 10/22/2021 10/22/2022 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 tF yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/iinvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 ..---( C 1 Daniel M.Cry,CPCU,Vice President—Residual Market—WCRIBMA @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD �o CERTIFICATE OF LIABILITY INSURANCE DATE(MAUDDIYYYY) ....--/ 2/13/2022 ilS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CS4RTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Partners Insurance Group,LLC NAME:A�Diane Lima-Ferreira 73 Alden Road ►E„.am:508-491-3663 I FAX,,tr 508-491-3108 Fairhaven MA 02719 ADDREss: dferreiraiPartnersinsgrpiic.com INSURER(S)AFFORDING COVERAGE NAIC 0 INSURER A:Capitol Specialty Insurance Co INSURED PROMO-1 Pro-Mod Homes LLC INSURER B MAPFRE Commerce 34754 12 Robin Lane INSURER C: Pocasset MA 02559 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:484543609 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR ADDL Vo TYPE OF INSURANCE INso W POLICY NUMBER 1 YUBR POLICYE�YTI (POLICY DCP UNITS A X COMMERCIAL GENERAL LIABILITY Y Y CS18006356-04 10/4/2021 10/4/2022 EACH f CLAIMS-MADE X OCCUR DAMAGE TORRENCE RENTED $1,000,000 PREMISES(Ea occurrence) $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $2,000,000 X 1 POLICY I 1 yea ECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ B AUTOMOBILE LIABILITY BCRJ36 6/13/2021 6/13/2022 OMB accidentINED LIMIT $1,000,000 ANY AUTO OWNED BODILY INJURY(Per person) $20,000 X AUTOSULED AUTOS ONLY HIRED BODILY INJURY(Per accident) $40,000 X AUTOS ONLY X AUTOSONLDY (Per accident)PROPERTY DAMAGE $ $ UMBRELLA LIAB OCCUR EXCESS LIAR EACH OCCURRENCE $ CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ WORKERS COMPENSATION $ AND EMPLOYERS'LJABILITY I STARME I I ER ANYPROPRIETOR/PARTNER/EXECUTWE YIN OFFICER/MEMBEREXCLUDED7 n N/A EL.EACH ACCIDENT $ (Mandatory in NH) yes EL DISEASE-EA EMPLOYEE $ DESCRIPTIONIfOFd OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The Town of Yarmouth is named as an additional insured to the policy when requested by a written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth MA 02664 AUTHORIZED REPRESENTATIVE ACORD 26(2076/03) The ACORD name and logo are 01988-2016 ACORD CORPORATION. All rights reserved,_ og registered marks of ACORD -o - My 14a wiGS -- � �3 c crn- 02^c c ,z.s FaulJeLtE l4ocu.lefr 6z.t on s Core eW u1► _J1�1u r --L- tp ‘74,8 ee -cn. 6 yarn / l seittiic es Co sill, L CA-.5(,t/4-L_ _ bSS'9'l a t/Ai5I 9681.Z! Jt IV elec-T"lztC 14r+n- - 'orz. rkis, ®g-wec - LSFd Pr wA Los ►t Kxct*QA- i✓16 CO 1Tfm cr'ro,1S E p)oyen- /"luTtu'L Crs. CO.__31i- , X$6 t Nl.rchAel 66I4- 1 t+_v►,. ,h C01111 a1ns. _&n-o 0u82g Be69Ro wts e, FutcC1 /io sfiR E-TlcJ1'1_ T Ave(ems Cri-su L7ty , s - # 8ciiu3938 Gh 33 - ` 4 balk8 - ttN bo34-� - Z � _ P. -VA tea--1• s Tuck c (A)e$eo rms. G Wive 35 2423.7 7-Pt nec. e/soTht v S p� �'r"'T 3z '1-P tS Co. -* -rww z6`? 1 78 . ICON = LEGACY ? CUSTOM MODULAR HOMES tic May 13, 2021 To: Building Inspector in the Commonwealth of MA Re: Letter of Certification in accordance with The State Board of Building Regulations and Standards—The Massachusetts State Building Code-780 CMR 110.R3.5.1.1 and all specialized codes-Licensed Construction Supervisors and Certified Installers To Whom It May Concern: This letter is to certify that Brunelle Modular Erectors Corp/Jonathan Brunelle("Brunelle"),an independent contractor, is experienced in the installation of Icon Legacy Custom Modular Homes, LLC("ILCMH") manufactured modular units, and has registered with ILCMH. ILCMH has provided Brunelle with the required processes related to the installation of ILCMH manufactured modular units. Brunelle is responsible for and required to perform all installation procedures in accordance with the current approved ILCMH Set and Installation Manual, including but not limited to, lifting and installation procedures of the manufactured modular units,and required fastening and anchoring of the manufactured modular units,to assure the safe and proper placement and connection of the manufactured modular units to the field installed foundation. This letter shall remain in effect for one(1)year from the date of issuance unless terminated in writing by either party(Brunelle or ILCMH). Brunelle is responsible to provide information regarding any change in the status of their liability insurance. Termination of said liability insurance for any reason shall make this letter invalid. Sincerely, f i,,2,?Ar f / Bruce Bingaman Sales Manager ICON Legacy Custom Modular Homes, LLC 246 Sand Hill Road ' Phone 57o-374-328o I Fax 57o-374-1122 1 iconlegacy.com Selinsgrove,PA 1787o SUBCONTRACTOR AGREEMENT Contractor: Icon Legacy Custom Modular Homes,LLC,246 Sand Hill Road,Selinsgrove,PA 17870(icon") Subcontractor. tAk.9JJL(. {O( (: iL ire_th/ Cft)p 1 �'\J t1,(i�,�c.�l-- k , (LI 9z Contractor desires to hire Subcontractor to perform certain work relating to the installation of the modules manufactured by Icon,known as Icon Serial Number /Order Number 10359("SN# /ON#10359"or the"Project"),for PRO-MOD HOMES,LLC.(the"Independent Builder"),as specified in 1.a.Subcontractor's Scope of Services in this Agreement("Work"),and Subcontractor desires to pertunis said Work at the price and upon the terms and conditions hereinafter expressed: The Contractor will provide copies of SN# /ON#10359's(i)Independent Third Party Agency approved plans("Approved Plans"),a copy of which is sent to the Independent Builder,and(ii)a copy of the as-built plans,as ordered,from Icon,by the Independent Builder(the"As-Built Plans"),a copy is shipped with the modules,to the Subcontractor.The Approved Plans and the As-Built Plans(together the"Plans")both are available(i)at the site, where the Project Is being erected,from the Independent Builder,(ii)at the Contractors place of business.And(iii)the Contractor will provide copies Of the Plans And the Contractor's Installation Manual(the"Set Manual"),to the Subcontractor via email,US Postal Service or by courier service.The Plans and I are made a part of this Subcontract Agreement insofar as they apply. The Subcontractor represents that it has(i)read this Subcontract Agreement,(ii)examined the Plans and the Set Manual and fully and completely understands them,and(iii)the Subcontractor's on site representative who will supervise the Work has examined the Plans and Set Manual and fully and completely understands them,or(iv)that both the Subcontractor and its on-site representative who will supervise the Work have both had the full and complete opportunity to do so; In consideration of the mutual agreements herein,the Parties contract,covenant and agree as follows: 1. Subcontractor's Scope of Services. a. Subcontractor shall provide the following erection and installation of the modules as specified in the Plans and the Set Manual;(i)place modules on the Independent Builder provided foundation using the crane or roll-on method,(II)bolt the modules together,(ill) permanently attach and affix the modules to the foundation,(iv)level floors,and(v)install Independent Builder supplied lolly columns as per the Plans,(vi)align end walls and roof to each other,(vii)perform all other services normally completed by the Set Crew,(viii) perform all other services agreed upon,and(ix)protect the modules from weather related damage at ail times during the performance of the Work,being sure to make the modules weather tight upon completion of the Work.The Work is to be competed to the full satisfaction of the Contractor and the Independent Builder.Subcontractor shall perform all Work and shall furnish all supervision,labor,materials, scaffolding,tools,equipment,supplies and other things necessary for the construction and completion of the Work as described in 1.a.of this Subcontract Agreement and to the satisfaction of the Contractor and Inds pendent Builder. [NOTE:There may be some variation in the Approved Plans and the A Burilt Plans.Refer to the Plans regarding the placement of foundation supports and all connections,which connections shall include,but shall not be limited to,rafter connections, module to module(box to box)connections,story to story connections,and all other connections,special or otherwise,shown on the Plans.' b. With respect to the Work covered by this Subcontract Agreement,and-except as expressly modified herein,Subcontractor shall have all rights which Contractor has,and Subcontractor shall assume all obligations,risks and responsibilities which Contractor has assumed towards the Independent Builder,and third parties as applicable,and Subcontractor shall be bound to Contractor in the same manner and to the same extent that Contractor is bound to independent Builder or said third parties. 2. Payment. a. Contractor shall pay Subcontractor for the performance of the Work described herein,subject to any additions and deductions as agreed upon in writing,the amount of 6000 dollars($6000.00),the quoted agreed upon amount,within three(3)business days of Contractor receiving full payment from independent Builder for satisfactory completion of the Work,providing all applicable paperwork has been submitted to Contractor.Both Contractor and Independent Builder must agree upon the satisfactory completion of the Work. Subcontractor accepts sole and exclusive liability for all taxes and contributions required of the Subcontractor by federal,state or local laws or regulations,induding,without limitation,the Federal Social Security Act and the Unemployment Compensation Law or similar laws in any state with respect to the employees of the subcontractor and the performance of the Work. 3. Subcontractor's Liability. Subcontractor shall be liable to Contractor for all costs Contractor incurs as a result of any failure of Subcontractor.Subcontractor hereby assumes the entire responsibility and liability for all work,supervision,labor and materials provided hereunder,whether or not erected in place,and for all tools,equipment,supplies and other things provided by Subcontractor until final acceptance,by the Independent Builder,of the entirety of the Work performed by the Subcontractor.In the event of any loss,damage or destruction thereof from any cause,Subcontractor shall be liable therefor,and shall repair,rebuild and make good said loss,damage or destruction at Subcontractor's cost,subject only to the extent that any net proceeds are payable under any insurance including,but shall not be limited to,property,risk, liability or other,that may be maintained by Independent Builder or Contractor. a. To the fullest extent permitted by law,Subcontractor shall indemnify,defend and hold harmless the Contractor,and it's respective officers,directors.employees and agents(Indemnified Parties")from and against all claims.damages.demands.mosc®s.axpenras, fines,causes of action,suits or other liabilities,(including all costs reasonable attorneys'fees,consequential damages,and punitive damages),arising out of or resulting from,or alleged to arise out of or arise from,the performance of Subcontractor's Work under this Subcontract Agreement,whether such claim,damage,demand,loss or expense is attributable to bodily injury,personal injury,sickness, disease or death,or injury to or destruction of tangible property,including the loss of use resulting therefrom;but only to the extent attributable to the negligence of the Subcontractor or any entity for which it is legally responsible or vicariously liable;regardless of whether the claim is presented by an employee of Subcontractor.Such indemnity obligations shall not be in derogation or limitation of any other obligation or liability of the Subcontractor or the rights of the Contractor contained in this Subcontract Agreement or otherwise. This indemnification shall not be limited in any way by any limitation on the amount or type of damages,compensation or benefits payable by or for the Subcontractor under any workers'compensation acts,disability benefits acts or other employee benefits acts and includes any loss or injury suffered by an employee of the subcontractor.This indemnification shall survive the completion of the Work or the termination of the Subcontract Agreement DISCLAIMER:ICON LEGACY CUSTOM MODULAR HOMES,LLC PROHIBITS ALTERATIONS TO THIS DOCUMENT AND ACCEPTS NO LIABILITY OR RESPONSIBILITY FOR ALTERATIONS MADE TO THIS DOCUMENT BY OTHERS. Subcontractor Agreement-Page 1 b. Subcontractor's assumption of liability is independent from,and not limited in any manner by,Subcontractor's insurance Coverage obtained pursuant to Paragraph 4,or otherwise. 4. Subcontractor's Insurance. Prior to commencing the Work,Subcontractor shall procure,and thereafter maintain,at its own expense,until final acceptance of the Work or later as required by the terms of the Subcontract Agreement,insurance coverage.At a minimum,the types of insurance and minimum policy limits specified in Exhibit"A".shall be maintained in a form and from insurers acceptable to Contractor.All insurers shall have at least an A- (excellent)rating by A.M.Best and be qualified to do business in the jurisdiction where the Project is located. Subcontractor and Contractor shall each carry its own Workers'Compensation Insurance. 5. Time of Performance. Subcontractor will coordinate its Work with the work of the Contractor,other subcontractors,and Independent Builder,so no delays or interference will occur in the completion of any part or all of the Project.Subcontractor will commence Work when directed by Contractor,or independent Builder,and Subcontractor will proceed with the Work in a prompt and diligent manner. TIME IS OF THE ESSENCE. 6. Change in Service. No amendment,modification,revision or other change to the scope of services hereunder,and any resultant change to compensation,must be set forth and agreed upon in writing and signed by Subcontractor and Contractor. 7. Assignment. Subcontractor shall not subcontract any portion of the Work or the Subcontract Agreement and shall not assign or transfer this Subcontract greement,without the prior written consent of Contractor. 8. Safety. Contractor makes no representations with respect to the physical conditions or safety of the Project site.Contractor assumes no liabilities related to the Project site.The project site is owned by the Independent Builder,the Indep endent Builder's customers,or others. a. Subcontractor shall,at its own expense,take all reasonable safety precautions in the performance of the Work to preserve and protect from injury its employees engaged in the performance of the Work and all property and persons which may be affected by its operations in performing the Work.At a minimum,the Subcontractor will comply with all applicable federal,state,and local laws,codes,rules, regulations,statues,ordinances,and requirements pertaining to the performance of the Work including the Federal Occupational Safety and Health Act("OSHA"). Subcontractor shall indemnify,defend and hold harmless Contractor and Independent Builder,and their respective officers,directors, agents and employees from and against any and all loss,which shall include,but shall not be limited to,loss of life and/or property,or any and all liability which shall include,but shall not be limited to,attomey fees,costs,fines and penalties,arising out of or related to Subcontractors failure to comply with the terms of this provision.Subcontractor agrees that all equipment brought onto the Project Site mcctc the applicable safety guidelines required by OSHA,and must be licensed and have a current inspection when applicable.Further, that all persons operating equipment have been trained through a program that meets minimum OSHA requirements. Under no circumstances will Contractor or Independent Builder release Subcontractor of responsibilities,concerning safety issues on the job site. b. Subcontractor shall take all reasonable precautions for the safety of,and shall provide all reasonable protection to prevent damage,injury or loss to all property on the Project Site,caused by Subcontractor.Any damage or loss of property caused in whole or in part by Subcontractor and/or Subcontractor's subcontractors),or their respective employees,shall be remedied without delay. 9. Certification.License and Registration. Subcontractor warrants that it has obtained all Certifications,Licenses,Permits and Registrations to,perform contracted Work in the State and Local Jurisdiction of performance and that said Certifications,Licenses,Permits and/or Registrations remain in good standing with the State and Local Jurisdiction in which the contracted Work is being performed. 10. Governing Law, This Subcontract Agreement shall be governed by and construed in accordance with the laws of the State of Pennsylvania without regard to conflict of law principals. 11. JURY TRIAL WAIVER. EACH OF THE PARTIES DOES HEREBY KNOWINGLY,VOLUNTARILY AND INTENTIONALLY WAIVE ITS RIGHT TO A TRIAL BY JURY iN RESPECT OF ANY LITIGATION BASED HEREON,OR ARIING OUT OF,UNDER OR IN CONNECTION WITH,THIS AGREEMENT,OR ANY COURSE OF CONDUCT,DEALINGS,STATEMENTS,OR ACTIONS OF ANY PARTY ARISING OUT OF OR RELATED IN ANY MANNER TO THiS AGREEMENT. 12. Presumption Arising from Authorship. Both Parties have had the opportunity to review this Subcontract Agreement with counsel and negotiate before signing this Subcontract Agreement.Therefore,there will be no presumption for or against either of the Parties arising out of the drafting of the Subcontract Agreement. 13. Waiver. The failure of either party to enforce,at any time,any provision of this Subcontract Agreement shall not constitute a waiver of such provision in any way or the right of such party at any lime to avail itself of such remedies as it may have for any breaches of such provision. 14. Entire Agreement. This Subcontract Agreement,including all Exhibits hereto,and other documents and plans referenced,contains all the terms agreed to by the Parties related to this subject matter.It replaces all previous discussions,understandings,and agreements. DISCLAIMER:ICON LEGACY CUSTOM MODULAR HOMES,LLC PROHIBITS ALTERATIONS TO THIS DOCUMENT AND ACCEPTS NO LIABILITY OR RESPONSIBttJTY FOR ALTERATIONS MADE TO THIS DOCUMENT BY OTHERS. Subcanbactor Agreement-Page 2 IN WITNESS WHEREOF,the Parties,by their duly authorized representatives,have hereunto executed this Subcontract,on the day and year first above written. EXIBITS: A-Insurance Provisions WITNESS SUBCONTRACTOR BY 1 0 Neu AUL -' Alkylm AI>✓Zt PRINT NAME PRINT NAME q'Z-I. Zv2.4 QA)ua- DATE TITLE rLttie 1.(, xU4d l ictr, eytr, EMAIL 1- 4. SZ-fo. 6Sc cj PHONE WITNESS CONTRACTOR:Icon Legacy Custom Modular Homes,LLC BY PRINT NAME PRINT NAME DATE TITLE DISCLAIMER:ICON LEGACY CUSTOM MODULAR HOMES,LLC PROHIBITS ALTERATIONS TO THIS DOCUMENT AND ACCEPTS NO UABILITY OR RESPONSIBILITY FOR ALTERATIONS MADE TO THIS DOCUMENT BY OTHERS. Sabeantnadoes Agreement-Page 3 7 : • . 4-taw6Acei0'a co 9 2--- yf 74 1)1rY s ..fUa22.. 37: 613Anii:vH.1.1°31;11:... 1.!....4 t • ji-wtTY: w Y JCQ 91:9 'LL86s: - .-. r 'a: UNsswws�e-- , sziasnm3 S -- I tctruna VNNEINa•rnr4 13311,45 031V it 0 MIS. It f ,Sn • 1 G961.LI-SO It- 86 LZt'9SS w. .$ • r 4-, -rot a s, ,asr m •'' 7 # ;`aid �� F o CO Y ,s 1ii-:-- .. . -. : it CPh' 1L1 . Om! utnrj m P !1+ 3 s uun,�nooWattaNupati ei. alill Commonwealth of Massachusetts 4) Division of Professional Licensure Board of Building Regulations and Standards Constr-uttgniltYp$rvisor CS-023046 spires: 10/03/2023 JOHN E SMITji7 , 7 CHACE DRRJE A LAKEVILLE M9 • l `Y • Commissioner (lob K. tl&vnnhfa ./ ivr‹fnnnii o�fi r fefr:-i¢e rye i - t Office of Consumer Affairs&Business Regulation i HOME IMPROVEMENT CONTRACTOR i TYPE:individual Registration Expiration 1 11104(2022 JOHN SMITH '" " I. D/B/A SMITH D PMMT GROUP TRUST JOHN E.SMITH 7 CHACE DR. ..a'CG.72 LAKEVILLE,MA 02347 Undersecretary . ---, (:)! it.i* 3 •:!.. '-)t NN) WATER DEPARTMENT '.49 Buck isiam...i R,,,:;f1 '0.! YArMOU!-h. M A u2673 'j;kir? PLc-,( — • 11/440 cL. I.0 iite.5 , co AA._ BUILDING PERMIT APPLICATION FOR WATER DEPARTMENT SIGN OFF TRANSMITTAL FORM BUILDING SITE LOCATION: /As- 5utvorki Ave PROPOSED WORK:De,+.142) cornne, ,srit_ucr- Isfek3 ki40 dc4.(afx,h3/14 c- APPLICANT: x jcih el $ti4 iTh/ —/tiod. 1)0.0Ne.-.5 /PA2-0 ADDRESS: 1 TELIIIIONE: i..1- --Iptis-44-- RESIDENTIAL AND 'OR COMMERCIAL BUILDING Water Lkpartment: Detertnines Compliance of Water?Nxailability and or existing location Engineering Department: Determines Compliance for Parking and DNiinage (.` inser‘ation Commission: Determines Compliance to ‘Vetlands Act: i c. II lot(si border any type of ‘k.-ettands,stri%11T1S,ponds, rivers,ocean, l)ogs,boys, marshland, IF.T('.•. Ilealth Department: Determines Clnupliance to State and"Fown Regulations, i.e. requirements for Scptage Disposal and other Public I lealth Activiies Fire I:4million: Determines Compliance to State and I:own Requirements for Personal Safety, Property Protections. Le: Smoke Detectors. Sprinkler Systems.ete JO APPI til ANT SIGNATURE DATE OFFICE USE: COMNIENTS ON PERMIT APPROVAL OR DENIAI ic-71..‹.'76- (24,— A ''[.??t.,)1 L,.....d/Kil pi frE(/‘ --to 1.J -r-c-a }--o 6. A--rlor , ' (44 4-1 vi- 1 ' RE:VIENNA) KY WATER DIVISION(SIGNATURE) DATE tO 41,, • SERVICE NO. 1/4fR0 NAME c:;;'2' ,t AOf SET J C7rJ' L)t�KJ VILLAGE Lcio Jeh70JC METER NO. /16 6760/ 7GS J l„AO C 9W L- I i i 31 1 1/t .3 &it/AO e (7;a/ f + �GIe k Volie tl Li 1317-6 PRO-MOD HOMES LLC 1600 12 ROBIN LN POCASSET.NIA 02569-1784 5344903 PH:774.360-9600 t 973 i NIP. I' Yr„tt --^ "">orM r of-____.. ,.:tow " E..44 $ -2 70,C0d GtS 4f U_. "' tt rlt�lr locKLAN D TRUST 97_ Wtip Fort Alsrtsit wY2 tQSr' C ......._. sue S"""L 11•001,6000* 1:0 i 110447BI: 797300h/597o Commonwealth of Massachusetts Manufactured Buildings Program-Plan Identification Number Assignment Name of Manufacturer Icon Legacy Custom MC Identification Number Modular Homes, LLC 352 Third Party Identification Number 02 Project Title O# 10394 Use Group Single Family BBRS\OPSI Identification Number 016 8-2 2 Review Required All plans are reviewed by MA and a BBRS Number assigned when approved Date: 04/08/22 Manufactured Buildings Program From: Syno Tell Manufactured Buildings Program Re: Confirmation of Receipt of Building Plans &Assignment of BBRS\OPSI Identification Number (BBRS\OPSI I.D.Number) The Board of Building Regulations and Standards and Office of Public Safety (BBRS\OPSI) has received your building plans for the referenced project and has assigned the identification number noted above (in the block marked BBRS\OPSI I.D. Number). This number has been assigned for purposes of internal tracking methods. This number shall be used in reference to this project and on all future correspondences, inquiries and plan revisions. Thank you for your cooperation with this matter. Send all correspondences,inquiries and plan revisions to: Office of Public Safety&Inspections-Linda Shea 1000 Washington Sheet,Suite 710 Boston,MA 02118 Linda.shea@mass.gov Bbrs\forms2\manufacturedbldgplanid-06/2018 / of.Y4At t.. 4 TOWN OF YARMOUTH o in ,z 1 t•t6 ROU`it 28 SoLrruu!'ARMOUTl1 \1 SSACHUS IFS 02664-4-131 w„u, fi 1cirpkcfsc;sots)3911-2211,1 xi.1250 1 sit(MIS)760.41430 Engineering and Surveying Division Building Permit Res ielx Residential and/or Commercial Buildings Name of Applicant; 176 gm tilt/P4VflocL I oNw)ts Li-C Telephone or Lmiil Address. >Lit A;:. p -od - �11 Qqf �": a kg,/ cop7 /SGZ Proposed Building Location: / , s edii, V/e 6VC j.)1 AA Wn+ 9-1,1, Date Submitted 9 ,24/21_ Requirements for revicu- Please submit one(1)cup%of plans,to include I. t-or Residential: Site Man showing proposal andror existing buildings. proposed contours with bench mark.water service location,and septic system location. For Commercial: Site Plan showing details required by the Zoning Fay-lau°and revisions required by Site Plan review.if any. Note: Site plans must be signed and stamped by a Licensed Pnnf ssionai Land Surveyor and Engineer or Sanitarian. 2. House or Building- Floor Plants)and Elevation Plants) 3. One(1)copy of application. AmandaON on.Amende Lone,o=ErNmeanng Me •"`""" '"DPW 10/17/2022LimaDale mews, . s ome.zmeztai� szasoou• Re%'loved By: Date PLEASE NOTE Comments/Conditions: ipA4se gy,ii 7►'lY1 6 cu?Tf eo f i in 5 Tpd j AV 1C.f,!eit.,/ ho Proposed relocated driveway appears to encroach onto A tit '10'way'. Drain roof drains to drywell. Appears deck will Onet INICICat ed cover D-box and clean out. Retain stormwater onsite during and post construction. Parcel within high groundwater area. TOWN OF YARM()UTFi o• . WATER DEPARTMENT 99`Buck Island Road( MA*TACHEESE West Yarmouth, MA 0267i Telt,phone: ( 08) 771-7921 • tax: (SOW 771-7998 BUILDING PERMIT APPLICATION FOR WATER DEPARTMENT SIGN OFF TRANSMITTAL FORM BUILDING SITE LOCATION: /gy cSeiewIF.w 4 u PROPOSED WORK: Cov in.w- = (N(v(L(, kJ.,-__ 014 -e --. APPLICANT: � �7 _-_ ADDRESS: ( Z /? )2r - N el, P c6).5,,. j G Z57 TELPHONE: � ?.7 2 9 / 5 RESIDENTIAL AND /OR COMMERCIAL BUILDING Water Department: Determines Compliance of Water Availability and or existing location Engineering Department: Determines Compliance for Parking and Drainage Conservation Commission: Determines Compliance to Wetlands Act; i.e. If lot(s)border any type of wetlands, streams, ponds,rivers,ocean, hogs, boys, marshland, ETC... I lealth Department: Determines Compliance to State and Town Regulations, i.e. requirements for Septage Disposal and other Public Health Activites Fire Department: Determines Compliance to State and Town Requirements for Personal Safety, Property Protections, i.e. Smoke Detectors, Sprinkler Systems,etc 5-/q APPLIC SIGNATURE DATE OFFICE USE: COMMENTS ON PERMIT APPROVAL OR DENIAL (lur 44 ( 70 41- D A1es' ( )(fte,mfe -. ,& /nrl'? i-L__ rei? �Sc�e vy� /sus" ,� /JcPc,e ��- cos‹ raeArics sroe S19 G z 2_ L—L -- REVIE%\ BY WATER DIVISION(SIGNATURE) DATE ''�!t Doc: 1 , 453, 720 03-04-2022 3 : 52 - '' '�' TOWN OF YARMOUTH S" , R.t,r BOARD OF APPEALS 0= • �/a. DECISION •,4 ,,�_ . FILED WITH TOWN CLERK: February 11,2022 PETITION NO: 4929 HEARING DATE: January 27,2022 PETITIONER: Kelly A. & George K.Norwood PROPERTY: 185 Seaview Ave, South Yarmouth, MA Map 19,Parcel 33 Zoning District: R-25 Certificate#: 208819 MEMBERS PRESENT AND VOTING: Chairman Steven DeYoung,Mr. Igoe,Mr.Fraprie and Mr. Neitz Notice of the hearing has been given by sending notice thereof to the Petitioner and all those owners of property as required by law, and to the public by posting notice of the hearing and publishing in The Cape Cod Times,the hearing opened and held on the date stated above. The Petitioner was well represented by Kieran Healy of the BSC Group and with regard to property located at 185 Seaview Ave.,property owned by Kelly A. and George K.Norwood.The Petitioners seek to raze and replace an existing structure seeking relief by either Special Permit or Variance. The property is located in an R—25 Zoning District. Due to the proximity to wetlands, the Conservation Commission reviewed the proposed work to be done on the land and voted to approve the project to be built consistent with the Plan of Land, 185 Seaview Ave., South Yarmouth,Kieran Healy PLS, BSC Group dated 10/18/21. Mr. Healy provided the Board with representation of the lot coverage, and when completed,will be 24.7%with a ridge height of 31 feet. The existing structure is a three bedroom home and it will remain a three bedroom home. When constructed,the new home will be slightly greater in size than is the existing home to the southern side yard.Additionally,the north side setback will be slightly greater than the existing. The Board did receive correspondence inclusive of a letter from an abutter, John Sears III,who expressed concern as to the style of the building and the existence of a 15 foot right of way. The existence of this right away was felt by the Board to be helpful in considering the southerly side yard setback. The Board also received a letter in support of the project from abutters Anne and .. ATRUE COPY ATTEST: 1 .W144100440-4 !MC/TOWN CLERK t - 4 off Doc: 1,453, 720 03-04-2022 3: 52 Page 2 of 3 John Moynihan. No exhibits were received at the time of the hearing,nor did anyone speak in favor of the Petition or against the Petition. The Board felt that the proper relief would be for the grant of a Special Permit and that the criteria necessary for the grant of such relief was met in that the building,when constructed, would create no undue hazard, nuisance or congestion,nor would there be any substantial detriment to the existing or future character of the neighborhood or town. A motion was made by Mr. Fraprie, seconded by Mr. Igoe to grant the requested relief and the Board voted unanimously in favor of the motion,without conditions,and the Special Permit was therefore granted. The Petitioner requested that the relief sought by way of Variance be withdrawn,without prejudice. Mr. Igoe made a motion to allow the withdrawal as requested,which motion was seconded by Mr.Neitz and upon which the Board voted unanimously in favor. No permit shall issue until 20 days from the filing of this decision with the Town Clerk. Appeals from this decision shall be made pursuant to MGL c40A section 17 and must be filed within 20 days after filing of this notice/decision with the Town Clerk. Unless otherwise provided herein,the Special Permit shall lapse if a substantial use thereof has not begun within 24 months. (See bylaw §103.2.5, MGL c40A §9) Stg, Steven DeYoung, Chairman CERTIFICATION OF TOWN CLERK I, Mary A. Maslowski, Town Clerk, Town of Yarmouth, do hereby certify that 20 days have elapsed since the filing with me of the above Board of Appeals Decision #4929 that no notice of appeal of said decision has been filed with me, or, if such appeal has been filed it has been dismissed or denied. All appeals have been exhausted. W44,40E460044 ' Mary A. Maslowski A COPY ATTEST: MAR - 4 2022 .A-46.1946.4 2 iIUL1 1!lMC 1 TO N CLERK NAR - 4 20tt i. Doc: 1 , 453 , 720 03-04-2022 3 : 52 Page 3 of 3 -.�Y-Yqk COMMONWEALTH OF MASSACHUSETTS ,;} ' '� r TOWN OF YARMOUTH r Sf - BOARD OF APPEALS C +` yb • .... � - - Petition #: 4929 Date: March 4,2022 Certificate of Granting of a Special Permit (General Laws Chapter 40A, Section 11) The Board of Appeals of the Town of Yarmouth Massachusetts hereby certifies that a Special Permit has been granted to: Kelly A. & George K.Norwood 185 Seaview Ave South Yarmouth,MA 02664 Affecting the rights of the owner with respect to land or buildings at: 185 Seaview Ave, South Yarmouth,MA; Map#: 19; Parcel#: 33; Zoning District: R-25; Certificate#: 208819; and the said Board of Appeals further certifies that the decision attached hereto is a true and correct copy of its decision granting said Special Permit, and copies of said decision, and of all plans referred to in the decision,have been filed. The Board of Appeals also calls to the attention of the owner or applicant that General Laws, Chapter 40A, Section 11 (last paragraph) and Section 13, provides that no Special Permit, or any extension, modification or renewal thereof, shall take effect until a copy of the decision bearing the certification of the Town Clerk that twenty (20) days have elapsed after the decision has been filed in the office of the Town Clerk and no appeal has been filed or that, if such appeal has been filed, that it has been dismissed or denied, is recorded in the Registry of Deeds for the county and district in which the land is located and indexed in the grantor index under the name of the owner of record or is recorded and noted on the owner's certificate of title. The fee for such recording or registering shall be paid by the owner or applicant. 4, .....„ Sec), i Steven S. DeYoung, Chairman A TRUE COPY ATTEST: rtgintAlk-1 JOHN F. MEADE, ASSISTANT RECORDER !TOWN CLERK BARNSTABLE REGISTRY LAND COURT DISTRICT RECEIVED & RECORDED ELECTRONICALLY *AR - 4 2822 Cif•Y` % Conservation Office �I y Town of Yarmouth kgrantCcwarmouth.ma.us (�G ► 4. Conservation Commission "hYpRspRFt*V -: Building Permit Sign-off Application TO BE FILLED OUT BY BUILDING PERMIT APPLICANT: / S'� Building Site Location: l€95-- Ye/1 in erpi A V( ' M4�, I v 44, Map# t9 Lot(s)# 3 3 4 o" e0e2 Property Owner: borti Ncuil.uJOI D Date filed: 5/5727-- *Applicant: d (�u,./ 721 )pito /f't'od. l'Leie s G/ / 9 Applicant Address: `7_ feo lj t� [ "'Me_ Pcic_mt-s's O shy Email Jc/)741cPfac2 - MaDlioiv►eS . CO Li./ Telephone: 50 9 e/ A-56 Z., Proposed Project Description: 1 .g�iZ1.t c " �.kt15c eXrS7"/hS rt C�,. ).1ew 014.0 d t,1,g-w.-A c t e- Site Plan Title/Date:��a LetAL9L-- ( 6 I 1 I Z TO BE FILLED OUT BY CONSERVATION ADMINISTRATOR: Does the proposed project require a permit? Refer to: SE83- r DOA perm Comments from Conservation Commissiopproved Conditionally Approved Rejected Conservation Commission Sign-off Signature: ______,_.„,c Date: 61 22 *TO APPLICANT: All work-related debris shall be taken offsite or disposed in a legal upland location. At the end of each day, the area shall be clean and no debris shall be in the Resource Area. If work is permitted under an Order of Conditions, please arrange a pre-construction site visit with the Conservation Administrator. At the time of site visit, the MassDEP File Number sign must be installed, along with the erosion control/work-limit line. A copy of the Order of Conditions must remain on-site during construction. Please refer to the Order of Conditions for further details. . , , 1 Massachusetts Department of Environmental Protection Bureau of Resource Protection - DEP File Number: Request for DepartmentalWetlands Action Fee Transmittal Form Provided by DEP Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 A. Request Information 1. Location of Project a.Street Address b.City/Town,Zip c.Check number d.Fee amount Important: 2. Person or party making request (if appropriate, name the citizen group's representative):When filling9 P' P ): out forms on the computer, Name use only the tab key to Mailing Address move your cursor-do City/Town State Zip Code not use the return key. Phone Number Fax Number(if applicable) 6 ( 3. Applicant (as shown on Determination of Applicability(Form 2), Order of Resource Area Delineation (Form 4B),Order of Conditions (Form 5), Restoration Order of Conditions (Form 5A), or Notice of [J..tl ti Non-Significance (Form 6)): Name Mailing Address City/Town State Zip Code Phone Number Fax Number(41 applicable) 4. DEP File Number: B. Instructions 1. When the Departmental action request is for(check one): ❑ Superseding Order of Conditions—Fee: $120.00(single family house projects)or$245(all other projects) 0 Superseding Determination of Applicability— Fee: $120 El Superseding Order of Resource Area Delineation—Fee: $120 Send this form and check or money order,payable to the Commonwealth of Massachusetts,to: Department of Environmental Protection Box 4062 Boston, MA 02211 wpaform2 doc•Request for Departmental Action Fee Transmittal Form•rev 5118i2020 Page I of 2 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP File Number: L Request for Departmental Action Fee Transmittal Form Pfovided by DEP Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 B. Instructions (cont.) 2. On a separate sheet attached to this form,state clearly and concisely the objections to the Determination or Order which is being appealed.To the extent that the Determination or Order is based on a municipal bylaw,and not on the Massachusetts Wetlands Protection Act or regulations, the Department has no appellate jurisdiction. 3. Send a copy of this form and a copy of the check or money order with the Request for a Superseding Determination or Order by certified mail or hand delivery to the appropriate DEP Regional Office(see httosJ/www mass.goviservide-details/tnassdep-regional-offices-bv-community). 4. A copy of the request shall at the same time be sent by certified mail or hand delivery to the Conservation Commission and to the applicant, if he/she is not the appellant. wpatorm2 doc•Request for Departmental Action Fee Transmittal Form•rev 5/18/2020 Page 2 of 2 . t�• 4 Massachusetts Department of Environmental Protection Bureau of Resource Protection -Wetlands WPA Form 2 - Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Town of Yarmouth Wetland By-Law, Chapter 143 B. Determination (cont.) ❑ 6.The following area and/or work, if any, is subject to a municipal ordinance or bylaw but not subject to the Massachusetts Wetlands Protection Act: ❑ 7. If a Notice of Intent is filed for the work in the Riverfront Area described on referenced plan(s) and document(s),which includes all or part of the work described in the Request, the applicant must consider the following alternatives. (Refer to the wetland regulations at 10.58(4)c. for more information about the scope of alternatives requirements): ❑ Alternatives limited to the lot on which the project is located. ❑ Alternatives limited to the lot on which the project is located,the subdivided lots, and any adjacent lots formerly or presently owned by the same owner. ❑ Alternatives limited to the original parcel on which the project is located,the subdivided parcels, any adjacent parcels,and any other land which can reasonably be obtained within the municipality. ❑ Alternatives extend to any sites which can reasonably be obtained within the appropriate region of the state. Negative Determination Note: No further action under the Wetlands Protection Act is required by the applicant. However, if the Department is requested to issue a Superseding Determination of Applicability, work may not proceed on this project unless the Department fails to act on such request within 35 days of the date the request is post-marked for certified mail or hand delivered to the Department.Work may then proceed at the owner's risk only upon notice to the Department and to the Conservation Commission. Requirements for requests for Superseding Determinations are listed at the end of this document. ❑ 1.The area described in the Request is not an area subject to protection under the Act or the Buffer Zone. ® 2.The work described in the Request is within an area subject to protection under the Act, but will not remove,fill, dredge, or alter that area. Therefore, said work does not require the filing of a Notice of Intent. ❑ 3.The work described in the Request is within the Buffer Zone, as defined in the regulations, but will not alter an Area subject to protection under the Act.Therefore, said work does not require the filing of a Notice of Intent, subject to the following conditions (if any). ❑ 4.The work described in the Request is not within an Area subject to protection under the Act (including the Buffer Zone). Therefore,said work does not require the filing of a Notice of Intent, unless and until said work alters an Area subject to protection under the Act. Page 3 of 5 wpatorm2 doe•Oeterminatton of Applicability•rev 5,1812020 4 v[7 Massachusetts Department of Environmental Protection Bureau of Resource Protection Wetlands 'P orm 2 — Determination of Applicability Illik- Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Town of Yarmouth Wetland By-Law, Chapter 143 B. Determination (cont.) 0 5. The area described in the Request is subject to protection under the Act. Since the work described therein meets the requirements for the following exemption, as specified in the Act and the regulations, no Notice of Intent is required: Exempt Activity(site applicable statuatory/regulatory prnvisinns) ❑ 6.The area and/or work described in the Request is not subject to review and approval by: Name of Municipality Pursuant to a municipal wetlands ordinance or bylaw, Name Ordinance or Bylaw Citation C. Authorization This Determination is issued to the applicant and delivered as follows: ❑ by hand delivery on ® by certified mail, return receipt requested on 10/22/2021 Date Date This Determination is valid for three years from the date of issuance(except Determinations for Vegetation Management Plans which are valid for the duration of the Plan).This Determination does not relieve the applicant from complying with all other applicable federal,state, or local statutes,ordinances, bylaws,or regulations. This Determination must be signed by a majority of the Conservation Commission. A copy must be sent to the appropriate DEP Regional Office (see httpsi//www,mass.gov/service-details/massdeo-rj gional-offices- by-community) and the property owner(if different from the applicant). wpalorm2.doc•Delermmalron of Applicability•rev.5;10l2020 Page 4 of 5 4 LMassachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Form 2 - Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Town of Yarmouth Wetland By-Law, Chapter 143 C. Authorization (cont.) Signattuuress:L�, 4 �"�— Ed:w/t- /ic' 2 S ure Printed Name a r<: 1 4 Printed Name laic% eishOp Stg Ju e. / Printed Name 440 �� 0 772 017'705' L7 iti b-7 tur Printed Name PLL4.t 6 1-1(<f�J oS' Printed Name Signatur ��- Printed Name utf lea r n Signs re Printed Name Signature Printed Name D. Appeals The applicant,owner, any person aggrieved by this Determination, any owner of land abutting the land upon which the proposed work is to be done, or any ten residents of the city or town in which such land is located, are hereby notified of their right to request the appropriate Department of Environmental Protection Regional Office(see httos://www.mass.gov/service-details/massdep•reaionnl-officers-by- community) to issue a Superseding Determination of Applicability.The request must be made by certified mail or hand delivery to the Department, with the appropriate filing fee and Fee Transmittal Form (see Request for Departmental Action Fee Transmittal Form) as provided in 310 CMR 10.03(7) within ten business days from the date of issuance of this Determination. A copy of the request shall at the same time be sent by certified mail or hand delivery to the Conservation Commission and to the applicant if he/she is not the appellant. The request shall state clearly and concisely the objections to the Determination which is being appealed. To the extent that the Determination is based on a municipal ordinance or bylaw and not on the Massachusetts Wetlands Protection Act or regulations, the Department of Environmental Protection has no appellate jurisdiction. wpa1orm2 doc•Determination of Applicability•rev 5/18/2020 Page 5 of 5 OV-., , TOWN OF YARMOUTH ^x ;t o HEALTH DEPARTMENT ' .!,.,.»A` PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To be completed by Applicant: Building Site Location: / ' .,,>:>i2 V ,, I) v -i'' Prop sed Improvement: ( Q t o-l 15 -'_ rx is r , c 1) 6' -E' I P ( Oc w S. Applicant: z vt �' 11 D----44-a1D j_1(ThiA4 fa....5 Tel. No.: `,...)_ . ) Date Filed: Address: I Z Pc,l?/► t ti 2i � �dC b l e:-...-; l 0 z`�G `j� y/Z. N **Ifyou would like e-mail notification of sign off,please provide e-mail address: Owner Name: ( eG/ 1 e 1U-d i t..k..)0 Owner Address: / V'/i 1 7jt,ee bi2.1 it e Owner Tel. No.:97 e". 2 TZ.- j 3 3 RESIDENTIAL AND/OR COMMERCIAL BUILDING HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements , For Septage Disposal and other Public Health Activities. Please submit three (3) copies of plans, to include: (1.) Site Plan showing existing buildings, water line location, and septic system location; (2.) Floor plan labeling ALL rooms within building (all existing and proposed) — Note: Floor plans not required for decks,sheds, windows, roofing; (3.) If necessary, Title 5 application signed by licensed installer 'th fee. REVIEWED BY: rI 61 ---------.7 DATE: ( — a3 dN . t PLEASE NOTE COMMENTS/CONDITIONS: J .S." w S c t' �, LA,-- jJ -c. J cr 1'� ;U r D:,G>, I u5-e- — i 'It S,c�, 1 L 7< -e.A.M 1. .ci ✓.0 S , , r/U, -s ( 5D .: ct31a40i . 1— , vSrq __1-..c-" -�- a-� c ,r-/0c,e-- f l� car, U.S. DEPARTMENT OF HOMELAND SECURITY OMB No. 1660-0008 Federal Emergency Management Agency Expiration Date:November 30,2022 National Flood Insurance Program ELEVATION CERTIFICATE Important: Follow the instructions on pages 1-9. Copy all pages of this Elevation Certificate and all attachments for(1)community official, (2)insurance agent/company,and(3)building owner. SECTION A—PROPERTY INFORMATION FOR INSURANCE COMPANY USE Al. Building Owner's Name Policy Number: KELLY&GEORGE NORWOOD A2. Budding Street Address(including Apt., Unit, Suite, and/or Bldg.No.)or P.O. Route and Company NAIC Number: Box No. 185 SEAVIEW AVENUE City State ZIP Code SOUTH YARMOUTH Massachusetts 02664 A3. Property Description(Lot and Block Numbers,Tax Parcel Number, Legal Description,etc.) ASSESSORS MAP 19,PARCEL 33.TITLE IN CERTIFICATE#208819 A4. Building Use(e.g., Residential,Non-Residential,Addition,Accessory,etc.) RESIDENTIAL A5. Latitude/Longitude: Lat.41.6407 Long.-70.2169 Horizontal Datum: ❑ NAD 1927 0 NAD 1983 A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance. A7. Building Diagram Number 8 A8. For a building with a crawlspace or encosure(s): a) Square footage of crawlspace or enclosure(s) 873.00 sq ft b) Number of permanent flood openings in the crawlspace or enclosure(s)within 1.0 foot above adjacent grade 5 c) Total net area of flood openings in A8.b 1000.00 sq in d) Engineered flood openings? [I Yes ❑ No A9. For a building with an attached garage: a) Square footage of attached garage N/A sq ft b) Number of permanent flood openings in the attached garage within 1.0 foot above adjacent grade N/A c) Total net area of flood openings in A9.b N/A sq in d) Engineered flood openings? ❑Yes ❑ No t f,, a,. SECTION B—FLOOD INSURANCE RATE MAP(FIRM)INFORMATION B1.NFIP C tnmuniiY Name&Community Number B2.County Name B3. State YARMOUTH 250015 BARNSTABLE Massachusetts B4. Map/Panel B5. Suffix B6. FIRM Index B7. FIRM Panel B8. Flood B9. Base Flood Elevation(s) Number Date Effective/ Zone(s) (Zone AO, use Base Flood Depth) Revised Date 25001C0589 J 07-16-2014 07-16-2014 AE 11 B10. Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in Item B9: ❑ FIS Profile ❑x FIRM ❑Community Determined ❑ Other/Source: B11. Indicate elevation datum used for BFE in Item B9: ❑ NGVD 1929 ❑x NAVD 1988 ❑ Other/Source: B12. Is the building located in a Coastal Barrier Resources System(CBRS)area or Otherwise Protected Area(OPA)? ❑Yes ❑x No Designation Date: ❑ CBRS ❑ OPA FEMA Form 086-0-33(12/19) Replaces all previous editions. Form Page 1 of 6 OMB No. 1880-0008 ELEVATION CERTIFICATE Expiration Date:November 30,2022 IMPORTANT: In these spaces,copy the corresponding information from Section A. FOR INSURANCE COMPANY USE Building Street Address(including Apt.,Unit,Suite,and/or Bldg.No.)or P.O.Route and Box No. Policy Number: 185 SEAVIEW AVENUE City State ZIP Code Company NAIC Number SOUTH YARMOUTH Massachusetts 02664 SECTION C—BUILDING ELEVATION INFORMATION(SURVEY REQUIRED) C1. Building elevations are based on: ❑x Construction Drawings* ❑Building Under Construction* ❑ Finished Construction *A new Elevation Certificate will be required when construction of the building is complete. C2. Elevations—Zones A1-A30,AE,AH,A(with BFE),VE,V1—V30,V(with BFE),AR,AR/A,AR/AE,AR/A1—A30,AR/AH,AR/AO. Complete Items C2.a—h below according to the building diagram specified in Item A7. In Puerto Rico only,enter meters. Benchmark Utilized: GPS RECEIVER Vertical Datum:NAVD 1988 Indicate elevation datum used for the elevations in items a)through h)below. ❑ NGVD 1929 0 NAVD 1988 ❑ Other/Source: Datum used for building elevations must be the same as that used for the BFE. Check the measurement used. a) Top of bottom floor(including basement,crawlspace,or enclosure floor) 8.0 0 feet ❑ meters b) Top of the next higher floor 13.0 El feet ❑ meters c) Bottom of the lowest horizontal structural member(V Zones only) N/A ❑ feet ❑meters d) Attached garage(top of slab) N/A n feet ❑ meters e) Lowest elevation of machinery or equipment servicing the building 13.0 ❑x feet meters❑ (Describe type of equipment and location in Comments) f) Lowest adjacent(finished)grade next to building(LAG) 7.5 0 feet ❑ meters g) Highest adjacent(finished)grade next to building(HAG) 8.5 0 feet ❑ meters h) Lowest adjacent grade at lowest elevation of deck or stairs, including 7.2 0 feet ❑ meters structural support SECTION D—SURVEYOR, ENGINEER,OR ARCHITECT CERTIFICATION This certification is to be signed and sealed by a land surveyor,engineer,or architect authorized by law to certify elevation information. I certify that the information on this Certificate represents my best efforts to interpret the data available. I understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001. Were latitude and longitude in Section A provided by a licensed land surveyor? 0 Yes ❑No ❑Check here if attachments. Certifier's Name License Number KIERAN J.HEALY 48135 " 414S Title SURVEY MANAGER Company Name 0MAN.", BSC GROUP, INC auta HEALY NO. 11 try Address r",6 349 ROUTE 28, UNIT D City State ZIP Code WEST YARMOUTH Massachusetts 02673 Signa Date Telephone Ext. ' 05-12-2022 (508)778-8919 4586 C y all of this E 'on Certificate and all attachments for(1)community official,(2)insurance agent/company,and(3)building owner. Comments(including type of equipment and location,per C2(e),if applicable) THIS FLOOD ELEVATION CERTIFICATE IS BASED ON PROPOSED DRAWINGS. NO UTILITIES OR NON-WATERPROOFED MATERIAL ARE PROPOSED BELOW THE DESIGN FLOOD ELEVATION OF 12.0. FEMA Form 086-0-33(12/19) Replaces all previous editions. Form Page 2 of 6 OMB No. 1660-0008 ELEVATION CERTIFICATE Expiration Date: November 30,2022 IMPORTANT: In these spaces,copy the corresponding information from Section A. FOR INSURANCE COMPANY USE Building Street Address(including Apt., Unit, Suite,and/or Bldg.No.)or P.O. Route and Box No. Policy Number: 185 SEAVIEW AVENUE City State ZIP Code Company NAIC Number SOUTH YARMOUTH Massachusetts 02664 SECTION E-BUILDING ELEVATION INFORMATION(SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A(WITHOUT BFE) For Zones AO and A(without BFE),complete Items El—E5.If the Certificate is intended to support a LOMA or LOMR-F request, complete Sections A, B,and C. For Items El—E4, use natural grade,if available.Check the measurement used. In Puerto Rico only, enter meters. El. Provide elevation information for the following and check the appropriate boxes to show whether the elevation is above or below the highest adjacent grade(HAG)and the lowest adjacent grade(LAG). a) Top of bottom floor(including basement, crawlspace,or enclosure)is ❑feet ❑meters ❑above or ❑below the HAG. b) Top of bottom floor(including basement, crawlspace,or enclosure)is ❑feet ❑meters ❑above or ❑below the LAG. E2. For Building Diagrams 6-9 with permanent flood openings provided in Section A Items 8 and/or 9(see pages 1-2 of Instructions), the next higher floor(elevation C2.b in the diagrams)of the building is ❑feet ❑meters ❑above or LI below the HAG. E3. Attached garage(top of slab)is ❑feet ❑meters ❑above or ❑below the HAG, E4. Top of platform of machinery and/or equipment servicing the building is ❑feet ❑meters ❑above or ❑below the HAG, E5. Zone AO only: If no flood depth number is available,is the top of the bottom floor elevated in accordance with the community's floodplain management ordinance? ❑ Yes El No ❑ Unknown. The local official must certify this information in Section G. SECTION F—PROPERTY OWNER(OR OWNER'S REPRESENTATIVE)CERTIFICATION The property owner or owner's authorized representative who completes Sections A,B,and E for Zone A(without a FEMA-issued or community-issued BFE)or Zone AO must sign here.The statements in Sections A, B,and E are correct to the best of my knowledge. Property Owner or Owner's Authorized Representative's Name Address City State ZIP Code Signature Date Telephone Comments ❑Check here if attachments. Form Page 3 of 6 FEMA Form 086-0-33(12/19) Replaces all previous editions. OMB No. 1660-0008 ELEVATION CERTIFICATE Expiration Date:November 30,2022 IMPORTANT:In these spaces,copy the corresponding information from Section A. FOR INSURANCE COMPANY USE Building Street Address(including Apt., Unit, Suite,and/or Bldg.No.)or P.O.Route and Box No. Policy Number: 185 SEAVIEW AVENUE City State ZIP Code Company NAIC Number SOUTH YARMOUTH Massachusetts 02664 SECTION G—COMMUNITY INFORMATION(OPTIONAL) The local official who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete Sections A, B, C(or E),and G of this Elevation Certificate.Complete the applicable item(s)and sign below.Check the measurement used in Items G8—G10. In Puerto Rico only,enter meters. Gi. ❑ The information in Section C was taken from other documentation that has been signed and sealed by a licensed surveyor, engineer,or architect who is authorized by law to certify elevation information. (Indicate the source and date of the elevation data in the Comments area below.) G2 ❑ A community official completed Section E for a building located in Zone A(without a FEMA-issued or community-issued BFE) or Zone AO. G3 ❑ The following information(Items G4—G10)is provided for community floodplain management purposes. G4. Permit Number I G5. Date Permit Issued G6. Date Certificate of Compliance/Occupancy Issued G7. This permit has been issued for: ❑ New Construction ❑ Substantial Improvement G8. Elevation of as-built lowest floor(including basement)of the building: ❑feet ❑ meters Datum G9. BFE or(in Zone AO)depth of flooding at the building site: ❑feet ❑ meters Datum G10. Community's design flood elevation: ❑ feet ❑ meters Datum Local Official's Name Title Community Name Telephone Signature Date Comments(including type of equipment and location, per C2(e), if applicable) ❑ Check here if attachments. FEMA Form 086-0-33(12/19) Replaces all previous editions. Form Page 4 of 6 BUILDING PHOTOGRAPHS OMB No. 1660-0008 ELEVATION CERTIFICATE See Instructions for Item A6. Expiration Date:November 30,2022 In these spaces,copy the corresponding information from Section A. 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