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BLD-22-004255
w RECEIVU --� & TWO FAMILY ONLY-BUILDING PERMIT Town of Yarmouth Building Department `y JAN 28 2022 1146 Route 28, South Yarmouth,MA 02664-44924tV 1 508-398-2231 ext. 1261 Fax 508-398-0836 BUILDING DEPARTMENT Massachusetts State Building Code,780 CMR e,«.e .' sy. , — R kg Permit Application To Construct, Repair, Renovate Or Demolish _ a One-or Two-Family Dwelling i This Seeti For Official Use Only i Building Permit Number: -' 2— 23 Date Applied: 2 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: t _ 1.2 Assessors Map&Parcel Numbers t�3 Y .41k _ L_. -gyp C � ��t . I.la Is this an accepted street?yes ✓ tto _ :Vzap Nutuu:.: Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot la(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided { Required Provided fr." Si.; !s + is' tit- V ,r Al, # r 1.6 Water Supply:(M.G.h c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Private G Zone: Outside Flood Zone? ,,`+ Check if yesCa'� Municipal 0 On site disposal system ®' SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: v' - A t-- yisk["tn.9 it Ti, /144 Name(Print) City,State,ZIP a ._nd_ ' di 7--5 jj -6/ J : � 'i,r�,>E u44, .r ..,,.;.e >,,\fi,s f x, c.ij w°"• No.and StrEet Telephone " Email Address SECTION_ 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction Id Existing Building 0 Owner-Occupied 0 1 Repairs(s) 0 I Alteration(s) O I Addition 0 Demolition C'Accessory Bldg.❑ Number of Units i Other 0 Specify: Briieeff Description of Proposed Work2:-- ti�.tdl(, .. .2ik..v,.'t4'4,, -L3.e1� 'r140),J.)lillri)I%-. jIke- it y..^�-._f,:.-. L V. SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only (Labor and Materials) ( {,�.,.� I.Building $ ..7 Q �] I. Building Permit Fee:S Indicate how fee is determined: 2.Electrical $:AO lla Standard City/Town Application Fee 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $uCT`0,..).) 2. Other Fees: $ Cf U c :- - I 4.Mechanical (HVAC) $ -3s3.1 List: 2-4 j 5.Mechanical (Fire • . _ _ Suppression) $ Total All Fees:$ 6.Total Project Cost: $ /�;� v -- Check No.,Check Amount: Cash Amount: El Paid in Full 83 Outstanding Balance Due: E "t SECTION 5: CONSTRUCTION SERVICES 15.1 Construction Supervisor License(CSL) • <<"" A. !/� License Number Expirai Date Name of CSL Holder sG' List CSL Type(see below)_ L� s•t <�u... ' No.and Street Type Description SC-4�44,i i *id- J II Unrestricted uildiag p to 35,000 cu.f3.)� City/Town,State,ZIP ' R Restricted 1&2 Family Dwellin Iv1 ;Masa ' rRC 1 Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances & CtirtA I Insulation " , Telephone Email add ess D f Demolition {{ 5.2 Registered Home Improvement Contractor(HIC) HIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date V'1 L,d, it_ = _ t_T AA./ Na.and Street $1140114.,4 441/�G i f,�)l > GA 4j ca/ .S4"/U-11 !, . 1_I i it', g S --C,i7 4 — S 1ci Email aLdress City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.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 ler---^ No El 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 „ee..,,r, /Los fr,`jt.... to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's 'ame(Electronic Signature) //Z�,d Date — SECTION 7b: OWNER'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 and accurate to the best of my knowledge and understanding. i jA!Aa... Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: I. 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.mass.aov/dos 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) j�=j (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) S Number of fireplaces r /� � Habitable room count Number of bathrfirepl ces Number of bedrooms Type of heating system Number of half/baths /lh'�/ f, Ct4 j Number of decks/porches Type of cooling system Enclosed Open i 3. "Total Project Square Footage"may be substituted for"Total Project Cost" ' Sears, Tim From: Sears, Tim Sent: Friday, July 22' 20223:40PK4 To: ' skawmehU/corp@gnnaiioom' Subject: 34Lvnda|e Kevin, | have reviewed your updated information and there are some items needed. al/lectric disconnect letter ;--Zhe ....^.".. plans for /mvuzones are required toUnstannpedbya Registered DedgnProfessional plans are missing the connection detail page(s) �� 4/� Crane operator info Call if you have any questions Regards, Tirnothy Sears C8C) Deputy 8ui/ding [bnnnnissiOner Town ofYarmouth 500-398-I331Ext. 1259 Dai|to:tseam(@yanno \ .` 1 Sears, Tim From: Sears, Tim Sent: Thursday, February 10, 2022 9:31 AM To: 'shawmehillcorp@gmail.com' Cc: Grant, Kelly;Water Department Lima, Amanda Subject: 34 Lyndale Rd Kevin, I have reviewed your application for the Raze & Replace, and there are items needed; tter Health Department sign off(under review) \ i Conservation sign off '3. Engineering sign off \�4. Water Department sign off ` 5. FEMA Elevation certificate \( S S ('C\*. Submittal documents in ccordance with section 110.R3.8.1.2 of the 9th Edition State Building Code 7. Disconnect letter for G s& Electric e Please submit these items for review This email is considered a written denial of your permit application per Section 105.3.1 of the Massachusetts State Building Code. Section 105.3.2 states in part that "an application fora permit for any proposed work shall be deemed to have been abandoned 180 days after the date of filing, unless such application has been pursued in good faith" You may appeal this denial to the Building Code Appeals Board in accordance with M.G.L. c. 143 §100, within 45 days of this notice. Timothy Sears CBO Deputy Building Commissioner Town of Yarmouth 508-398-2231 Fxt, 1259 rnailto:tsearsPyarmouth.ma.us 1 EVERS e U RC E Eversource Energy 247 Station Dr,Westwood,Massachusetts 02090-9230 ENERGY September 6,2022 Fred Brundage 34 Lyndale Rd Bass River,MA 02664 RE: ADDRESS REMOVAL To Whom It May Concern: At Eversource,we're committed to delivering great service. This letter serves as confirmation that, as of August 29,2022 the electric service to above address has been removed. Based on this information,there is no electric power at this address. If you have any questions,please contact me at(781)441-3206 Sincerely, Eversource Electric Service Support Center nationalgnd RECEIVED1 [UN08 ; ]22 June 7, 2022 ______ $�IILD��G DEF?ARTAM Shawme Hill Corp. Kevin Hamlin 43 Water St. Sandwich, MA 02563 TO WHOM IT MAY CONCERN: RE 34 Lyndale Rd, Yarmouth, MA This email is to confirm that there is no live gas at this property. I can be reached directly at 508-760-7439 should there be any further questions. Sincerely, g43, Ellen Whelan Customer Connections, NE National Grid 127 Whites Path S. Yarmouth, MA 02664 CO 508-760-7439 CHARLES D.BAKER GOVERNOR EDWARD A.PALLESCHI ECRETARY OF KARYN E. POLITO Commonwealth of Massachusetts UNDEAFFAIRSAND BUSINE"SS MER LIEUTENANT GOVERNOR Division of Professional Licensure REGULATION MIKE KENNEALY Office of Public Safety and Inspections COLMMMI RR,DIIVVMIONIOF SECRETARY OF HOUSING AND 1000 Washington Street, Suite 710 PROFESSIONALLICEN8URE ECONOMIC DEVELOPMENT Boston, Massachusetts 02118 April 26, 2021 Mr. Richard Burnham Huntington Homes, Inc. 344 Fassett Road East Montpelier, VT 05651 RE: RECERTIFICATION FOR 2021 —2022 Commonwealth of Massachusetts Manufactured Buildings Program MC #: 083 TPIA#: 02 Dear Mr. Burnham: This letter is to confirm your recertification in the Commonwealth of Massachusetts Manufactured Buildings Program as a producer of Manufactured Buildings for the period of April 30, 2021 through April 30, 2022. This approval is contingent upon compliance with all previously listed conditions of your approval, and compliance with the provisions of the current Massachusetts State Building Code, Massachusetts State Electrical Code and Massachusetts State Fuel /Gas Code. Yours truly, BOARD OF BUILDING REGULATIONS AND STANDARDS Linda K. Shea Manufactured Buildings Program cc: PPS(TECO) i ;t TELEPHONE: (617)727-3074 FAX: (617) 727-2197 TTY/TDD: (617) 727-2099 http:/lwww.mass,gov/dpl Commonwealth of Massachusetts II Manufactured Buildings Program-Plan Identification Number Assignment Name of Manufacturer HUNTINGTON HOMES MC Identification Number 083 Third Party Identification Number 02 Project Title 10273 Revised Use Group Single BBRS\OPSI 0398-20 Identification Number Family Review Required All plans are reviewed by MA and a BBRS Number assigned when approved Date: 1 1 /05/2 1 Manufactured Buildings Program From: Linda Shea 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 Street,Suite 710 Boston,MA 02118 Linda.shea@mass.gov Bbrs\forms2\manufacturedbldgplanid-06/2018 5/12/22, 12:34 PM 10273 Brundage(MA)Rev#2.pdf 2.2 y Download v Sign in 0 .1444.. Commonwealth of Massachusetts * , )., Manufactured Buildings Program.Transmittal Formfor all correspondences relating to :, ,,__ ,- :_ Manufactured Buildings and Building Components .): Linda Shea, Manufactured Buildings Program Phone Number: Date Transmitted linda.shea@mass.gov 617-826-5225 2-7-22 Dmmonwealth of Massachusetts Office of Public Safety and Inspections Attn: Manu. Bldg Dard of Building Regulations and Standards 1000 Washington Street, Suite 710 oston Massachusetts 02118 ie person forwarding this material shall complete the following portion of this transmittal ame of Person Richard Burnham MC Number MA Number ransmitting Material Huntington Homes, Inc. 083 02 'ie following information is being transmitted to the Board of Building Regulations Please indicate the Distinct id Standards and I or the Department of Public Safety for reasons detailed below Model. and/or Serial Use lease check the appropriate box or give a further description of the transmitted Number pertaining to Group ,ms under the section labeled other. Be sure to identify the appropriate Use Group.) transmitted items uilding Plans for Review and Approval .gilding Plans forwarded as a record copy for your files ,,eview not required) evised building plans for review. _._ _.._._ ..._._..._._.. _ 'lease clearly identify revisions on the plans.) Brundage #10273 single famil evised Building Plans forwarded as a record copy for your files review not required - Please clearly identify revisions on the plans.) )mpliance Assurance Programs Original Submission Modification to: L� 3lculations Manual Original Submission Modification to: stallation Manual Original Submission Modification to: rsterns Drawings Original Submission Modification to: ther- Provide a detailed description BBRS#0398-20 REV any other materialspp w (3), '"noittortV i0ertA of . Iuu L.a1 I IIIQI!aye yvul pei ultai jIICIeI eIIL,ea at UUI LAP,O\ :“.if r7CI IL IVV'. - - - -• -• Decline https://www.dropbox.com/s/Ij8jrclvzxpjtlx/10273 Brundage%28MA%29 Rev%232.pdf?d1=0 1/1 7.-,777•% HUNTINGTON SINCE /578 March 21, 2022 RE: Certified Installers— Letter of Certification To Whom it May Concern: This letter is written documentation that the following personnel have been adequately educated and trained in the procedures related to the field installation of modules produced by Huntington Homes, Inc. Such procedures include the safe placement of the modules onto the Owner's foundation. By issuing this letter, Huntington Homes, Inc.hereby certifies that the listed personnel are knowledgeable and competent to perfoiiii all work associated with placing the modules onto the foundation. The following is a list of Certified Installers: • Scott Perry • Ralph Davis a Paul Osborne • Adam Lambert • Janus Fournier • Kevin Dunn • Kurt Whitehead • Matthew Veilleux • Dave Pecarcik • Chad Hubbard 6 Chris Willey * Jeff Haskins O Cole Haskins If there are any questions relating to this matter, I can be contacted at(802) 479-3625 x111. Respectfully, Zrad:** Scott Perry Operations Manager Huntington Homes, Inc. A`CO,REP CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 4/25/2022 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(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 CONTACT Eastern Insurance Group, LLC. NAME: Kimberly Pelopida 233 West Central Street PHONE �191C.No.Est): 508-620-3380 FAX 233 No 5086514680 Natick MA 01760 APDRRESS: kpelopida@easterninsurance.com INSURERS)AFFORDING COVERAGE NAIC 0 INSURER A:Firemen's Ins Co of Wash,D.C. 21784 INSURED 10936 INSURER S:Acadia Insurance Company 31325 Huntington Homes Inc _ 344 Fassett Road INSURER C:Technology Insurance Company 42376 East Montpelier VT 05651 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:630133137 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 POLICY EFF POLICY EXP INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS B X COMMERCIAL GENERAL LIABILITY CPA5069148-19 1/1/2022 1/1/2023 EACH OCCURRENCE $1,000,000 DAMAGE TO IRENTED CLAIMS MADE [X I OCCUR PREMISES Ea occurrence) $300,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY X jECOT- X LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY CAA5069150-19 • 1/1/2022 1/1/2023 COMaaccBINideEDnt)SINGLE LIMIT $1,000,000 (E ANY AUTO BODILY INJURY(Per person) $ AUTOS ONLY X• SCHEDULED BODILY INJURY(Per accident) $ X HIRED X NON OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ B X UMBRELLA LIAB �X OCCUR CUA5081086-19 1/1/2022 1/1/2023 EACH OCCURRENCE $5,000,000 EXCESS LIAS CLAIMS-MADE AGGREGATE $5,000,000 DED RETENTION$ $ C WORKERS COMPENSATION TWC4058810 1/1/2022 1/1/2023 X :MUTE EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNERJEXECUTI VE OFFICERlMEMBEREXCLUDED? N/A E.L.EACH ACCIDENT $500,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under _DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) 34 Lyndale Road South Yarmouth, MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Frederick Brundage Jr. ACCORDANCE WITH THE POLICY PROVISIONS. Dawn Brundage 75 Wendell Park AUTHORIZED REPRESENTATIVE • Milton MA 02186 CAPPluemom.Q ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD A`CCoRI$ CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 4/25/2022 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(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 CONTACT Eastern Insurance Group, LLC. NAME: Kimberly Pelopida PHONE 233 West Central Street �{c.No.Ext): 508-620-3380 FAX No):5086514680 Natick MA 01760 ADDuREss: kpelopida@easterninsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A:Firemen's Ins Co of Wash,D.C. 21784 10936 INSURER B:Acadia Insurance Company 31325 Huntington Homes Inc 344 Fassett Road INSURER C:Technology Insurance Company 42376 East Montpelier VT 05651 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1446937041 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 ADDL SUBR LTR TYPE OF INSURANCE INSD.WVD POLICY NUMBER POLICY EFF POLICY EXP (MM/Dp/YYYY) (MM/DD/YYYY) LIMITS B X COMMERCIAL GENERAL UABILITY CPA5069148-19 1/1/2022 1/1/2023 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES Ea occurrence) $300,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY X jE 9 XJ LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY CAA5069150-19 1/1/2022 1/1/2023 COMBINED SINGLE LIMIT $1,000,000 ANY AUTO (Ea accident) BODILY INJURY(Per person) $ OWNED AUTOS ONLY X, AUTOSULED BODILY INJURY(Per accident) $ X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident)_ $ - _ $ B X UMBRELLA LIAB X OCCUR CUA5081086-19 1/1/2022 1/1/2023 EACH OCCURRENCE $5,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $5,000,000 , DED RETENTION$ $ c WORKERS COMPENSATION TWC4058810 1/1/2022 1/1/2023 X STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? N/A E.L.EACH ACCIDENT $500,000 (Mandatory In NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 1 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 34 Lyndale Road South Yarmouth,MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Shawme Hill Corp. 43 Water Street Sandwich MA 02563 AUTHORIZED REPRESENTATIVE ellie12114Q ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD *,--\ The Commonwealth of Massachusetts uDepartment of Industrial Accidents -- I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Name (BusinesslOrganizatiorJlndivicual): l�' / Please Print Leoibt r ti.,/ Address: y' l — .iia City/State/Zip: A4 ' ' � Phone#: V--4t/S"` �'S Are you an employer?Check the appropriate box; 1.0 i am a employer with employees(full and/or part-time).- J ; f jPe 'project(required); ?-�f l am a sole proprietor or partnership and have no employees working for me in �' ''e�'construction • any capacity.(No workers'comp.insurance required.) 8. Remodeling 3.0 I am a homeowner doing all work myself.(No workers'comp,insurance required.]r 9- e;nolition 4.0 I am a homeowner and will be hiring contractors to conduct ail work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 10❑Building addition t proprietors with no employees, 11.0 Electrical repairs or additions 5-�am a general contractor and I have hired the sub-contractors listed on the anached sheet. 1 2'❑plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.t 13. Roof repairs 6.0 we are a corporation and its officers have exercised their right of exemption per,MMGL c. �-t I52,§1(4),and we have no employees.(No workers'comp.insurance required.) 1�'❑Other 'Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContractors 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'con policy P P y number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site bifornration. insurance Company Name: r c i :e.. Policy or Self-ins.Lie,; : yt fs — Expiration Date; Job Site Address:_ Attach a copy of the vworkers co mpensatton pile City/State/Zip: ii, �J . jj,' ! y declaration page(showing the 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 DIA for insurance coverage verification. 1 do hereby certify under the pains and penalties of perjury that their formation provided above is trite and correct. Signature: " Phone n: _ / r Date: / 7 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4. ElectricaI Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 Fax 508-398-0836 Office of the Building Commissioner BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Ch. 40, §54 and 780 CMR- Section 105.3.1. #4. I hereby certify that the debris resulting from the proposed work/demolition to be conducted at Si 4/4...t)oh- 4 Work Address Is to be disposed of oat the following location: Jh . s t`f�_ Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. /A/44 Signature of Application Date Permit No. / \ 4r � �_1, 3 �rn � _rt Ta 2tA ° * -1 0 z»6 \ ) & ems fge \a>2 * ? ( x2i 0 - < 0 d/ m )[ <, i � Zr— ? 7\) 2�� �� 2 �� ` � � § \ - � d) \ . ƒ( § iv ) i, )jj \ . {:4 \ ao 2=7\� ^ , c,=6 §} » . IL .f ) k IL z� 4� m ©2 Cr \(3� �G ƒ w } ; / >x o, . \ § 2r \ / m/\\ \ ; c §( �" » } � ° o= J � , a/ < o ( m \ o: : a \ 73-,,I. 4 a < } ~ 7 \ i , AC RO O® CERTIFICATE OF LIABILITY INSURANCE I DATE(MMlDD YYYY) �/ 01/27/2022 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(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 CONTACT Lisa Fonseca NAME C&S Insurance Agency,Inc. PHONE (508)339-2951 FAX 190 Chauncy St MA No,Ext): (A/C,No): (508)339 48,1 ADDRESS:L LISa @CandSIIIS.COm INSURER(S)AFFORDING COVERAGE NAIC# Mansfield MA 0204E Central Insurance Companies INSURER A: p INSURED INSURER B: Shawme Hill Corp. INSURER C: 43 Water Street INSURER D: INSURER E Sandwich MA 02563 INSURER F COVERAGES CERTIFICATE NUMBER: 2021 Cert of Liab 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 ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MMJDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY — EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES Ea occurrence) $ 50,000 MED EXP(Any one person) $ 10,000 A CLP 8690649 08/05/2021 08/05/2022 1,000:000 PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000.000 POLICY LOUPRO- JECT I ) PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER $ — AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) _ ANY AUTO BODILY INJURY(Per person) $ A OWNEOSDONLY X AU SCHEDULED BAP 8690650 08/05/2021 08/05/2022 BODILY INJURY(Per accident) $ AUT XHIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY X AUTOS ONI.Y !Per accident) $ X UMERELLALIAB OCCUR 1,000.000 EACH OCCURRENCE $ A EXCESS LIAB CLAIMS-MADE CXS 8690651 08/05/2021 08/05/2022 AGGREGATE $ 1,000.000 DED I I RETENTION 5 WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY Y/N X STATUTE OTH- ER ANY PROPRIETOR/PARTNER/EXECUTIVE 1;000, A 000 OFFICER EXCLUDED? I N I N/A WC 8690652 08/06/2021 08/06/2022 E,L.EACH ACCIDENT $ (Mandatory In NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below 1,000,000 E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if 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 Fred Brundage ACCORDANCE WITH THE POLICY PROVISIONS. 34 Lyndale Rd. AUTHORIZED REPRESENTATIVE ' South Yarmouth MA 02664 ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD S ACORD CORPORATION, All rights reserved. Commonwealth of Massachusetts Manufactured Buildings Program-Plan Identification Number Assignment Name of Manufacturer HUNTINGTON HOMES MC Identification Number 083 Third Party Identification Number 02 Project Title 10273 Revised Use Group Single BBRS\OPSI Identification Number 0398-20 Family Review Required All plans are reviewed by MA and a BBRS Number assigned when approved Date: / 57 LI 11 /0 L/2 1 Manufactured Buildings Program From: Linda Shea 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 Street,Suite 710 Boston,MA 02118 Linda.shea@mass.gov Bbrs\forms2\manufacturedbldgplanid-06/2018 40' Commonwealth of Massachusetts Manufactured Buildings Program Transmittal Form for all correspondences relating to ` 'i Manufactured Buildings and Building Components To: Linda McAlister ractured Buildings Program Phone Number: Date Transmitted linda.shea@mass.gov 617-826-5225 10/12/21 Commonwealth of Massachusetts Office of Public Safety and Inspections Attn: Manu. Bldgs. Board of Building Regulations and Standards 1000 Washington Street, Suite 710 Boston Massachusetts 102118 The person forwarding this material shall complete the following portion of this transmittal Name of Person Richard Burnham MC Number TPIA Number Transmitting Material Huntington Homes,Inc. 083 02 The following information is being transmitted to the Board of Building Regulations Please indicate the Distinct and Standards and/or the Department of Public Safety i'or reasons detailed below Model and/or Serial Us (Please check the appropriate box or give a further description of the transmitted Number pertaining to Grou items under the section labeled other. Be sure to identify the appropriate Use Group.) transmitted items p Building Plans for Review and Approval Building Plans forwarded as a record copy for your files (Review not required) Revised building plans for review. (Please clearly identify revisions on the plans.) X Brundage #10273 single family Revised Building Plans forwarded as a record copy for your files (Review not required-Please clearly identify revisions or the plans.) I Compliance Assurance Programs Original Submission Modification to: Calculations Manual Original Submission Modification to: Installation Manual Original Submission Modification to: Systems Drawings Original Submission I I I I Modification to: Other-Provide a detailed description Changed Windows from Marvin to Andersen.Updated HERS accordingly. of any other materials which are being Changed m iscellaneous finish materials shown on plans.Switched transmitted. Identify any revisions clearly responsibilities of miscellaneous cabinets to be by builder.Eliminated carrying along with BBRS number. Also, identify the requested action. beams at basement stair and applied loads to basement stair columns/footings. BBRS#0398-20 Site Location: 30 Lyndale Road,Yarmouth,MA 02664 The office transmitting this information has reviewed the above mentioned and attached materials and has found them,to the best of our knowledge and abilities, to be in compliance with the codes and\or rules and regulations for the Commonwealth of Massachusetts'Manufactured Building Program, as applicable D gitally signed by Harold Raup Signed ByD :cn=Harold Raup,o=PFS,ou, for TPIA: c US it=harold.raup@pfsteco.com, Signed By BBRS No: assigned by Mass. for MASS: D te:2021.10,12 14:08:34-04'00' I IPrint Form I 0 o o 2° W m uoi , o e Or-" €11ggIGI L � ' aN Eo �� iC 0 LLy. 4 = q u 't2.M1 i h a) stp, Ciu tla, - rti ' C-0 O Z Q I ti v al n X C V, c 7 ro 1/1 •y O "� v• C CU O Q to Q N mew CT) 6 n1 QI w CI— c w Lri0 ro v ° ( C (U Q. ,p W 0 O w ry C�se 2 .N 0 A. 40 oc c mo. x> a .: vp v v to Q} E G ro — f° w e a m= `w+5 2 EiiiJ 4C H «WAI 00 C Tr- v— a a'> _ own T 0.qr RS Z_ .0.r. o RI c w 7.1 O o R a C a' p Q Y M >- 03,, F— V N (e w ct a s u, a 8 ,1-0 o ., . i.; E co u_ v.) 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P 1 gi i g "E i u t:1! / EA / i9 i i i kQg ! 1 1; 1 0 it! 1 1 li I —V 1 ; I 1 2 4 il 2 f c , i .4 if ill i : 20 1 mil Lattit Ili! ! 0 Rt ; kb* :1 ; Igilii ..stl g1R . : UJ relg 011 ; : - glipig D g !I - . _ g5 .n s.7 4,, , — e : 4y1 d o f ad at C a6 z n ._ ti Z H CO D a_ ' V { �.. s W C` \t \ 9 � a. 5 L II - as 1 . , \ ,', ' . ' 1 i M 1 ,- F _`4 r 9 T I Q 12 g�. r cAi.I R D I i I,g2—°;;I 1 ill 11 r r 4 i 5 G ei li r.$ O Conservation Office tS ftr- { _'y Town of Yarmouth kgrant{ryarmouth.ma.us Conservation Commission Building Permit Sign-off Application TO BE FILLED OUT BY BUILDING PERMIT APPLICANT: Building Site Location: Map # Lot(s)# ' 111 Property Owner: '(4 -L. 4 4,-;2 _ Date filed: }AY 4 4 2022 `Applicant: K•K.-v- 1/41,4.ts, By Applicant Address: '1,.5' c k Email: SAIki,Miciu if<kj 4? -p141L,. Telephone: .5,( 2'-'1 '.;; Proposed Project Description: L � ` �„ p7 .,Awx-. � �� Coiwe 0.. v AO Site Plan Title/Date: '; Si "4Z CA T l ' -Cet. ?t 0+ TO BE FILLED OUT BY CONSERVATION ADMINISTRATOR: Does the proposed project require a permit? Refer to: SE83- or DOA permit / Comments from Conservation Commission: Approved ,, Conditionally Approved Rejected Conservation Commission Sign-off Signature: e4Date: *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. .01.1rdlit TOWN OF YARMOUTH 1146 ROL,YE 28 SOUTH YARMOUTH NLASSACEIL:SErrS 02664-4451 N6") 44aecealt.0*'c(.7" Telephone(508) 398-2231, Ext. 1250—Fax (508) 760-4830 Engineering and Surveying Division Building Permit Review Residential and /or Commercial Buildings Name of Applicant: Telephone or Email Address: Lw_diLd—A4/24 C404 Proposed Building Location: SV jt . Date Submitted: - Requirements for review: Please submit one (1) copy of plans, to include: 1. For Residential: Site Plan showing proposed and/or existing buildings, proposed contours with bench mark, water service location, and septic system location. For Commercial: Site Plan showing details required by the Zoning By-law and revisions required by Site Plan review, if any. Note: Site plans must be signed and stamped by a Licensed Professional Land Surveyor and Engineer or Sanitarian. 2. House or Building - Floor Plan(s) and Elevation Plan(s) 3. One (I) copy of application. Amanda Digesily signet"by Amanda Lim. Lima Date 2022 02 16 12 48 52-0500 Date: 2/16/2022 Reviewed By: _ PLEASE NOTE Comments/Conditions: drain roof drains to dry wells, keep stormwater on site during and post construction. tt, Printed on Recycled Paper rri "-ttk 3: V ...4 , , ' iiie ell ,A3 E P 7 = 0 .r•,,,,,,,,,,t .... g r 1� ,.:A), , ,,, 7 a � ""$1 o d � ` � + d' y i`...� 'L 44,1. . ., "ftY, l 'Yfe14'.. .yyy 1 �`'P fi{ r APS i i • •�t1 e ,)�' I ;Y F Fd kx b tt �. t +F r "' f N slow ' e F K $ r" . .4° 1 f �N y p�" � " n tri a i. �, §p� 44� ;' F .,� 0 «,_ .t Fp n ,, M tea. ,, Ito)" ".^ +r ,, t ,f,' " "' ` "� ' b r 3 ,,a,c„.t ,,,k TOWNR �'�OF YA MOUTH tmr HEALTH DEPARTMENT ., ' PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET .?. To he completed by Applicant. r'1 Building Site Location: 3 y' �- �f 3 /.-:_ i- ;,) Proposed Improvement: ,,i. r e, ;,_-. r Applicant: X ' r . , cx1 ,fit . Tel. No.;: '- ', -S:a Address: :y,/ 1,7.,, , ,42 ,. (--) Date Filed: /r�,,4` <,,, **If you would like e-mail notification of sign off please provide e-mail address: ,17404/014 i /41 «i dt eQ72 (Jl14l f, C 7 Iv, Owner Name; c,. v ) , i (II N3e_6- Owner Address: 3 cre r.. f.t�st-1� ,�.i) �'r�?�,K`fv�i V Owner Tel. No /7..' c9 -6I 42 RESIDENTIAL AND/OR COMMERCIAL BUILDING HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements j 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 with fee. 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