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0120 BAXTER ROAD
/ao �3�x�.�. k�� - — � - -- � a 1 TABLE RUC f a ipfond Commercial Builder °'� ar s q A fi6!Q]SPBClALFST ': QUfiLI`I �d Ta` d G4 _j 3 March 15, 2014 i l Town of Barnstable Thomas Perry CBO Building Commissioner 200 Main Street Hyannis, MA 02601 RE: Insulation Permits Dear Mr. Perry, This affidavit is to certify that all work completed for permit application#201400938;Status A; Parcel 310096 at 120 Baxter Road, Hyannis, MA; Permit Type RADD and issued on 12:00:00 AM has been inspected by a certified Building Performance Institute(BPI) inspector. All work performed meets or exceed Federal and State requirements Sincerely, Michael McCarthy McCarthy Construction TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Ma ( C)_ Parcelo9 1,P d�9 3 1 p Application # Health Division Date Issued Z Z o- N Pic Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address Village Owner Address So- � Telephone '73 L-1-2-1 G-Set/ Permit Request .Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation K " Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑"/ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full 0 Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) � d Number of Baths: Full: existing new Half: existing - new.=. Number of Bedrooms: existing _new Q Total Room Count (not including baths): existing new First Floor Room';Count - ' a Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other rn Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/c9al stove:_❑Yq82❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Mike McCarthy Construction Telephone Number PO Box 52 Address West Dennis, MA 02670 License# ' Cell (508) 280-6%4 C'SL-58633 HIC-169393 Home Improvement Contractor# Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE r rr FOR OFFICIAL USE ONLY << APPLICATION# DATE ISSUED t MAP/PARCEL NO. ADDRESS VILLAGE E OWNER DATE OF INSPECTION: ' FOUNDATION FRAME INSULATION FIREPLACE i. it C r, ELECTRICAL: ROUGH FINAL F PLUMBING: ROUGH FINAL r GAS: ROUGH FINAL 4 FjNAL BUILDING 1. DAT6wCLOSED OUT a AWOO ION PLAN NO. r The Commonwealth of Massachusetts Department of IndustrialAccidents L Office of Investigations ' 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/organiZation/lndividual): Mike McCarthy Construction Address: West Dennis, MA 02670 Cellz8o-6964 City/State/Zip: CSL-58633PhRIC-169393 Are you an employer?Check the appropriate box: Type of project(required): L 1. ffey 1 am a employer with 7 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition workingfor me in an capacity. employees and have workers' Y P tY t 9. ❑Building addition [No workers' comp. insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.[ ther comp.insurance required.] *Any applicant that checks box#1 must also fill 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. $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: Policy#or Self-ins.Lic.#: QQ �pp Expiration Date: Job Site Address: V�i k i.a. 1�-Q City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.0.0 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..Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify er pains and penalties ofperjury that the information provided above is true and correct Si afore: Date: Phone#: 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.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as""an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual partaeR ship,associationgor other legal entity,employing employees. However the K,i owner of a dwelling house having not more than three apartments-and'who resides therein,or the occupant of the dwelling house of another who ref t ploys,persons'to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant'�the�eto sha`hiioi becaiise of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also•states`that"every state ar'%eal licensing agency shall withhold the issuance.or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have. employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call.the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits.or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFB Revised 4-24-07 Fax#617-727-7749. v .m v di ass o / a it OWNER AUTHORIZATION FORM r (Owner's Name) owner of the property located at (Property Address) t (Property Address) ' - � '�hereby authorize � �:e� �� 11 � � �a j , (Subcdntractor): Y 0 an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. Owner's Signature Date s DATE(MMIDD/YYY1� .ACi;Z CERTIFICATE OF LIABILITY INSURANCE TE(MIVV DN 013 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 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 01962-001 ;CONTACT NAME: Bryden 8 Sullivan Ins Agcy of Dennis Inc �A/C.No.Ext)__(508)398-6060 FAN.No: (508)394-2267 -- --- --------- -.....----. .L- - - ----------- --- PO Box 1497 I aooREss: So Dennis,MA 02660 L --- - -------------------�- ----... NAIC# .__.. INSURER A: A.I.M.Mutual Insurance Company - - 33758 INSURED Michael McCarthy Construction Inc P 0 BOX 52 INSURER SURER C:------.----------____-- West Dennis,MA 02670 INSURER D ___-___ I INSURER E_-=---- - - - ---- -- -- ._......_ COVERAGES CERTIFICATE NUMBER: 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 CONDITICNS OF SUCH POL!CIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS. ILTR TYPE OF INSURANCE i1ND5PR�WV60 POLICY NUMBER-- --T MM%DD EFF (MM/DDY EXP---- - LIMITS --— - - -- - - - --- - 1 C —) YYYL i-- - -- GENERAL LIABILITY �. ! EACH OCCURRENCE $ - II ---- - COMMERCIAL GENERAL LIABILITY I j ! DAMAGE TO RENTED �$ PREMISESaoccurrence) --.. h---- �--------- I CLAIMS-MADE OCCUR j ;MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL -A --_AGGREGATE 1$ - ENERAL 6EN1 AGGREGATE LIMIT APPLIES PER. ! I PRODUCTSCOMP/OP AGG .$ PRO- 1 i _. _ --- _... .--— )_ POLICY JECT. i tOC ............. . AUTOMOBILE LIABILITY I 7 COMBINED SINGLE LIMIT - l(Ea acc;dent1. $ ANY AUTO I I I BODILY INJURY(Per person) $ iALL OWNED .. I SCHEDULED ------ - - - ------- ---- AUTOS AUTOS IBODILY INJURY(Peraccident) $ HIRED AUTOS j I NON-OWNED PROPERTY DAMAGE $ F-- AUTOS ! I F(Per accident) $ UMBRELLA LIAB OCCUR i I EACH OCCURRENCE h$ EXCESS A CLAI MS LIAB S MADE ! GGREGATE $ . . - -- --... - -. - -- �. ------ - - 1 _. DED _ RETENTION $-- - - - - -- ------- --- --- $ - - -I- ---- -- -- -r- X ORYTATU-' OTH - - T R WOoRKERS COMPENSATION T LIMI S E A<JD EMPLOYERS'LIABILITY I -�.— 1._ AN PRpPRIETOR/PARTNER/EXECUTIVE� -_I i ( E.L.EACH ACCIDENT $ 500,000,QO A OF ICEWMEEM9BEER EXCLUDED? y I N/A VWC-100-6017656-2013A 7/17/2013 7/17@014 r-_._-._._._..._.. YIN (Mandatory In NH) --I � E.L.DISEASE-EA EMPLOYEE$ 500,000.00 6��9901 TciON�nF OPERATIONS below. j I I _- T $ 500,000.00 ...... ._.. _.. _.._. -- --- -._ s.._.. ...._..__ .._I.' - ---- F L DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION TOWN OF SANDWICH Attention:BLDG DEPT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN HALL ANNEX THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED, IN Sandwich,MA 02563 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. \'ORD 25(2010/05) The ACORD name and logo are registered marks of ACORD . a, , �1e`�oan��ao�rzcoealC1 a�C�oac/u�eGY�. \ Ofrlce.of Consumer Affairs&Busi ess Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistratio.w, •169393 Type: Office of Consumer Affairs and Business Regulation xpiration: 6/16/2015-. Individual 10 Park Plaza,-Suite 5170 Boston;MA 02116 MICHAEL MCCARTHY� ¢t MICHAEL MCCARTHY 3 k 6 RANGLEY LN. SOUTH DENNIS, MA 02660 Undersecretary ANtvalid without signature i i Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Sulict s isor ~ .. License: CS-058633 T ' MICHAEL J McCARTHY I. 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September 7,2012 310110 310083 310109 #9 310432 310093 f #297 #201 #188 '427 �� 310100 #27 #21 v 310108 R #94 310082 #207 (� _p v 310094 #194 310069 ' , 310054 #15 #83 310431 310081 s . f#285 � #213 - 310098 lop w #7 �4 .�, 310055 #91 310334 #219 31009 310,056 #114 #977 = j 310090 310095 #225 #134 ,F "310096 ' n310057 #103 `r+ 0058 31,Or #23 310079 #237 310060 310059 #137 I A 310-ilk 437 #119 #131 310043 : 310042 #2458. 310061 � #236 310062 `�'" 310349 010077 36 et #242 #69 DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:310 Parcel:096 boundary determination or regulatory Interpretation. Enlargements beyond a scale of Owner:LABDIE,ERNEST C&ANITA A,TRS Total Assessed Value:$111700 Selected Parcel W+ 1"=100'may not meet established map accuracy standards. The parcel lines on this map . are only graphic representations of Assessor's tau parcels.They are not true property Co-Owner:LABADIE FAMILY LIVING TRUST Acreage:0.11 acres Abutters boundaries and do not represent accurate relationships to physical features on the map Location:120 BAXTER ROAD ,^ such as building locations. Buffer E/ Town of Barnstable *Permit 0r ;n Expires 6 mond-sham issue da Regulatory Services Fee Thomas F.Geiler•,Director' Building:Division .Tom Perry,CBO, Building,Commissioner 200 Main Street,Hyannis,MA 02601 www.town.6 arnstab l e.ma.us Office: 508-862-4038 Fax:508-790-6230 EXPRESS PER HT APPLICATION - RESIDENTIAL ONLY Q/ , Not Valid without Red X-Press Imprint Map/parcel Number 210 Property Address I d� '7C! 1� mo Is Y 1 l c z(s [ Residential Value of Work -9[t4 1 57. u V Minimum fee of$25.00,for work under$6000,00 Owner's Name&Address I�f !( � Qi Contractor's Name Telephone Number ���•" Home Improvement Contractor License#(if app icable) 1 . I S 1 O Construction Supervisor's License#(if applicable) { 113 ❑Workman's Compensation Insurance Chp k one: Lv I am a sole proprietor JUN 11 2012 ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name Workman's Comp,Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) dRe-roof(stripping old shingles).All construction debris will be takeneto ❑Re-roof(not stripping. Going over existing layers of ro o fl ❑ Re-side, ❑ Replacement Windows/doors/sliders. U-Value ( qq) "Whcre required: Issuance of this permit,.does not exempt compliance xdth other town department regulations,i:e.Historic,Conservation,etc. ' ***Note: Property weer sign Pro WE Letter of Permission. cop of the Ho e Improv ent Co ors License is required: SIGNATURE: Q:Forms:expmtrg Revise061306 Of IHE y j z 'Town of Barnstable. . .� Regulatory Services i HARNSTASLE, • - . y MAC $ Thomas F. Geller,Director �AIFDa �A Budding Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Off m: 508-862-403 8 Fax: 508=790-6230 Propeity Owner Must Complete and Sign This Section If Using A B uild.e as Owner of the subject property . hereby authorize r 2 to act on MY bebalf, in all matters relative to work authorized bytL& building Permit-application for:. a {Address of r. Signature of Corner ate V 4& Print Name QTORMs:GWNERP RMISslorr The Commonwealth of Massachusetts :a Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lelzibly Name (Business/Organization/Individual): o'�,np : Address: City/State/Zip: n 1' 14 O'Ko o.I Phone.#: Are you an employbrW. Check the appropriate box: Type of project(required); 1.❑ I am a employer with 4. I am a general contractor and 1 nployees(full and/or part-time). # have hired the sub-contractors 6. ❑New construction" 2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' 9. Building addition. [No workers' comp.insurance comp, insurance.# 5. 0 We are a corporation and its ME] Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work officers have exercised their 1 LF®Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. oof repairs insurance required.]t c,. 152, §1(41,and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill 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'comp:policy number. i. I'atit al.i4mployer that is providing;workers''eompensat►oif insuraeice for.mytemployees.;.Below.is the policy and job s►te ;, information. Insurance Company Name:. Policy#or Self-ins.Lic.#: _. Expiration Dater Job Site Address: City/State/Zip: Attach a'copy of the workers'.compensation policy declaration page.(showing the.policy number and expiration date). Failure to secure coverage as required under:Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1SOO:OO and/or one.=year.:imprisonmenti as well asi.civil penalties in the:fortn gf a.,$TOP`WORK,ORDER;and a fne of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DLAf6rjnsura verage verification.. I do h e y certi tertpai s.a penalties of perjury that the information provirrde affbIve`is true and correct.. Si ature: Dater 110 110 Phone#: , Official use only:.Do not wrtte::in this area...to be completed bycity or.town offteiai;. City or'Towti Permit/License# Issuing Authority(circle one) ' .. 1.Board`of IiealtH 2.;'Buildmg.D'epartrrientr73.City/Torvri:Clerk 4.Electrical Inspector;:S:.PI'uinbing Itspeetor :... . 6.Other Contact Person: Phone#: _ �r .-.tei _•�+�,. m.: �Im --�, a"' .�'s ^ci ."��: S�Y`�,'r`+� rn�..'7a�• s� .)'.">�y -'rt.�'k��c`t=ce7�� ^'e G "'� .:'';� '' itc �,.: Y-�t "R .fl•,. , „-„3 �'` w o � -h ,t.`E 'ts1.v ��..` (L-' .._�.«''r.';•--.fir-�'�+ sc - � s, �,rxx"tE. k .-�`�v a.>,.. ,�`• �'.3r'•�s, :-r rw:..{� •3-- -Art'. ,4���_ c4i..,�:-,j.: �..-e.;�';.3, Y� a. .,.st`'y - �;»e=r .:",�.r.s+.�. :n de'—{`-w=E ..w� '3�.- ne .r �.r... 7 �a :. �t� ..s -a ....: _,:, X'-e� , t �n*'•,� ':t, :,w-o- w .m �' - .,,,{ fx,r� _ xY -�F. ,'�+.• £ --F-.F;,YT.... `.-y; ?CS 1" 4 4' :4...b.Y . � ,..aim,�- .. - Al:.r._, .:, r....y •�'� .. � ... :... � .may,• .a1, � x:1', ~•r ...us.� �,:yr r ., d ..�A:a -._..., t _.,., o-,:. w: �. -,_: - E t 7h', i l ------------ oi r y - yr;2'e''ri6'E � im,;,,,' 6Di-.L''4.1A{�•• r. - _ - - EE 5 is't3 i'"i� -'F..;b x�t •,�.,F,a x+ - r [ t ,,.,; �S � _ - .� ..- i TtS=`L k'uk NS�'.w.,%%rG� 5.rf.. � !:• t¢ �2.i t- sv� � we h -:i. - - { .,..�' `:�i _ ¢ - y Z-..'L.'�c�.,i:.S.r} ! 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