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1132 BUMPS RIVER ROAD
l�� a � ���. �. � - k i qHE r Application number�......'�... ........... • Date Issued................. .t. . ° BARHiSTABI.E, ° A'MAS& 183Q. �0i' ® Building Inspectors Initials......... .... . ............. AUG 0 12019 Map/Parcel.........../8g...�3..1................................ TOWN OJ 8-ARNSfABLF TOWN OF BARNSTABLE -�� EXPEDITED PERMIT APPLICATION: ROOF/SIDINGI%9NDO WS/DOORS/TENTS/STOVES/WEATHERIZATION F---IPROPERTY INFORMATION Address of Project: _ //3,Z NUMBER STREET VILLAGE Owner's Name: ,, i ; hP� Phone Number ,`v k-kz 7- 7o G 5- Email Address: Cell Phone Number 7,�s- Project cost$ // pow Check one Residential vl Commercial OWN-kR'S AUTHORIZATION As owner of the above property.I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: S e �-{{Q�� C��s�.-(c -� Date: TYPE OF WOE Siding 0 Windows (no header change)# 0 Insulation/Weatherization Doors (no header change).# 2- Commercial Doors require an inspector's review �-1 Roof(not applying more than 1 layer of shingles) / n Construction Debris will be going to Grl a S4e-12 4a a 9 PdIP/1 CONTRACTOR'S INFORMATION Contractor's name I�r�Gn `74n�,'so� So 2�� dew cr lov,z kill•nr(owS Home Improvement Contractors Registration(if applicable)# 17 3 2_q_) (attach copy) Construction Supervisor's License# bg E 7 07 (attach copy) Email of Contractor st ee+ q e- • C M1 Phone number 110/- z z R -1 X ALL PROPERTIES THAT HAVE STRUCTURES VER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER............................................................ *For 'Vents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached:Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. *WOO➢)/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand any responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMIt the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the'Town of Barnstable. Signature Date AI"PLICANT9S SIGNATURE Signature Date 7- 31 -/4 All permit applications are subject to a building official's approval prior to issuance. J Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home I mprovement,Contractor Registration Type: Supplement Card SOUTHERN NEW ENGLAND WINDOWS LLC;= Registration: 17324577 Expiration: 09/18/2020 10 RESERVOIR ROAD -•...: =` — - SMITHFIELD, RI 02917 - - SCA 1 20M-05/ Update Address and Return Card. C� r1-/T � P- TGY/7/J2/.YI,CL'P,O.GlJL C G'�Oiri!/.(.�I.CG)GCIii Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:.Supplement Card before the expiration date. If found return to: Reaistratibn,._ Expiration Office of Consumer Affairs and Business Regulation 1'.Z3245_ 09/18/2020 1000 Washington Street-Suite 710 SOUTHERN NEW ENGLANO WINDOWS,LLC Boston,MA 0211 BRIAN DENNISON� ,Q 10 RESERVOIR ROAD u SMITHFIELD,RI 02917 Undersecretary ito Without Signature Y _ Commonwealth of Massachusetts ty Division of Professional Licensure Beard of Building Regulations and Standards Constrmfion `Supervisor , CS-095707 � p E0 i res: 09108/2020 BRIAN D DENNISON 8 BLACKWELL DRIVE CHARLTON MA=0150? COI'YtM'issioner f The Commlonweddi,of plassacltusetts Department of Industyid Aceddents 1 Congress Street,.Suite 100 Boston,M4 02114--3017 www miTss gov/&ia A urkers'Compensation Insurance A6d2vih Builders/Contractors/Electriciaas/Plumbem TO BE FILED WITH THE PER.HiTTLYG AUTHORITY. Applicant Information L1s l / { Please Print Levibly Name(Business/otgartization/Individual): _S t�G�`I'�e 1'1. 1Ve U.) �w / W//)�r Address:_-U � City/State/Zip:-5M t-H1A 1'1d,l?( OZ9 l] Phone#: 40l-2,Z,9- gtoy _ Ara you an employer'Check the appropriate box: Type of project(required): 1. I am a employer with 204 employees(full andlor part-time).• 7. ❑New construction am a sole proprietor or partnership and have no employees working for me in 8: Remodeling any capacity.[No workers'comp.inmrnce required] ❑ 3.01 am a homeowner doing all work my'selE(No workers'comp,insurance required.]t 9. ❑Demolition 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 D Building addition ensure that all contractors either have workers'compensation insurance or are sole 11. 3 Electrical repairs or additions proprietors with no employees. 12.[1 Plumbing'repairs or additions 5.❑1 an a general contractor and I have hired the sub-cormraetors listed on the attached sheet These sub-contractors have employees and have workers'comp.insu<ance.t 13.❑Roof repairs 6.[3 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E3&er O d h-) 152,§1(4).and we have no employees.(No workers'warp.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 conttactam must submit a new affidavit indicating such. kontracmrs that check this box must attached an additional sheet showing the name of the sub•connactots and state whether or not those entities have employees. If the sub-contactors have employers,they must provide their wort='comp.policy-number. I am an employer that is providing workers'compensation insurance for Pry eNW10yem Below is the policy and job site tnformadoit: Insurance Company Name: a - �� �• (� , Policy#or Self-ins.Lic.#: IAXA-,31,5 7-01 y Expiration Date: Job S ite Address:L . __T_ �, �_ —!v /• City/State/Zip: .t �r 1�2 A Attach a copy of the workers'compensation policy declaration page(showing the policy number and expire 'on date). Failure to secure coverage as required under MGL c. 152,125A is a criminal violation punishable by a fine up to S 1.500.00 and/or one-year imprisonment;as well as civil penaltids in the form of a STOP WORK ORDER and it 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 veri kation. I do hereby ce under the p penalnies of perjary that the infamod en provided above is h7w and correct 4 � i Date: Phone#: QQicial use only. Do not write in this area,to be completed by city or town odIciai City or Town: Permit/License# Issuing Authority(circle one): LCORMCt ealth 2.Building Department 3.CitytTown Clerk 4.Electrical Inspector 5.Plumbing Inspector n: Phone#• I AC® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 11%. .f I 12/28/2018 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 CONTACT CoBiz Insurance, Inc.-CO NAME` 1401 Lawrence St., Ste. 1200 ITCNo, o E • 303-988-0446 arc No:303-988-0804 IL Denver CO 80202 ADDREss: COMail@cobizinsurance.com INSURE S AFFORDING COVERAGE NAIC p INSURER A:Acadia Insurance Company 31325 INSURED ESLERCO Ot Southem New England Windows, LLC. INSURER B:Firemens Insurance Company of WA,D.C. 21784 dba Renewal by Andersen of Southern New England INSURER C:Homeland Insurance Company of New York 34452 10 Reservior Rd INSURER 0: Smithfield RI 02917 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:787175890 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. I� TYPE OF INSURANCE SR ADDL SUBR . POLICY NUMBER MMIIDICDY/YYYY MMIDDIYYYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CPA3158728 1/112019 1/112020 EACH OCCURRENCE $1.000,000 CLAIMS-MADE a OCCUR DAMAGE TO REM PREMISES Ea occurrence $300,000 MED EXP(Any one person) $t0.00D PERSONAL 8 ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 O. POLICY FACTLOC PRODUCTS-COMP/OP AGG $2.000.000 X l0 OTHER: $ A AUTOMOBILE LIABILITY CPA3158728 1/1/2019 1/1/2020 CO M8INED SINGLE LIMIT ide $(Ea1 0 00 X ANY AUTO BODILY INJURY(Per person) $ ALL AUTOS OWNED AUTOS U�D BODILY INJURY(Per accident) $ X HIRED AUTOS X AUTOS NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ $ A X UMBRELLA LIAB X OCCUR CPA3158728 1/1/2019 1/1/2020 EACH OCCURRENCE $15,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $15,0m.000 DIED I X I RETENTION$ $ B WORKERS COMPENSATION WCA315872924 1/1/2019 1/1/2020 X STATUT'E ER AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? N❑N/A E.L.EACH ACCIDENT $1.000.000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $1,000,00D N yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 C Pollution Liability 7930073340000 1/1/2019 1/1/2020 Each Occurrence $2,000,000 Claims-Made Policy Aggregate $Z,�Op0p00 Retroactive Date 06/2012013 Deductible DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) e r 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. FOR INFORMATIONAL PURPOSES ONLY AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Renewal Agreement Document and Payment Terms byAndersen. dba:Renewal B Andersen of Southern New England Y g Monty&Marianne VanBeber Legal Name:Southern New England Windows,LLC 1132 Bumps River Rd RI#36079,MA#173245,CT#0634555, Lead Firm #1237 Centerville,MA 02632 WINDOW RE LACEMENT 10 Reservoir Rd I Smithfield,R1.02917 H:(508)827-7065 Phone:866-563-2235 1 Fax:401-633-6602 1 sales@renewalsne.com C:(785)338-1708 Buyer(s)Name: Monty & Marianne VanBeber Contract Date: 07/20/19 Buyer(s)Street Address: 1132 Bumps River Rd , Centerville, MA 02632 Primary Telephone Number: (508)827-7065 Secondary Telephone Number: (785)338-1708 Primary Email: drmoony@hotmail.com Secondary Email: Buyer(s) hereby jointly and severally agrees to purchase the products and/or services of Southern New England Windows,LLC d/b/a Renewal By Andersen of Southern New England("Contractor"),in accordance with the terms and conditions described in this Agreement Document and Payment Terms,any documents listed in the Table of Contents,and any other document attached to this Agreement Document,the terms of which are all agreed to by the parties and incorporated herein by reference(collectively,this "Agreement"). Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Total Job Amount: $11,008 By signing this Agreement,you acknowledge that the Balance Due,and the Amount Financed must be made by personal check,bank check,credit card,or cash. Deposit Received: $5,504 Balance Due: $5,504 Estimated Start: Amount Financed: $11,008 8 to 10 weeks Method of Payment: Financing, We schedule installations based on the date of the signed contract and secondarily on the date in which we complete the technical measurements.The installation date that we are providing at this time is only an estimate.We will communicate an official date and time at a later date. Rain and extreme weather are the most common causes for delay. Notes: Taxes included ; 5504. From G5;Permit pd ck$56. Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alterations to or deviations from this Agreement will be valid without the signed,written consent of both the Buyer(s) and Contractor.Buyer(s)hereby acknowledges that Buyer(s) 1)has read this Agreement,understands the terms of this Agreement,and has received a completed,signed,and dated copy of this Agreement,including the two attached No of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement. NOTICE TO BUYER:Do not sign this contract if blank.You are entitled to a copy of the contract at the time you sign. YOU,THE BUYER,MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 07/24/2019 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. Legal Name:Southern New England Windows,LLC dba:Renew#By Buyer(s)en of Southern New England rs) Signature of Sales Person Signature Signature Paul McLean Monty VanBeber Marianne VanBeber Print Name of Sales Person Print Name Print Name UPDATED: 07/20/19 Page 2 / 11 f� .Town of Barnstable //�� 11 *PerOI�#.21J I I 0{{I 3zz J� Expires 6 months from:issue date s, Regulatory:Services, Fee �!S, i i u � Thomas F.Geiler,Director s639:'p�0 . . FD 1.1 MAy r,:l; :k 6 2,01 Building Division Tom Perry,CBO,'Building Commissioner OWN OF BARNSTABLE 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax:-508-790-62A EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press imprint Map/parcel Number 1 Property Address Residential Value of Work `i Minimum fee of$35.00 for work under$6000.00 Owner's Name&AddressQR 11oN�. Contractor's Name O.L-w 2 y. Telephone Number 6'©i5 .ij<>0l 'A- Jo c{fl Home Improvement Contractor`License#(if applicable)_ I—M"M " Construction Supervisor's License#(if applicable) j ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ am the Homeowner Q I have Worker's Compensation Insurance Insurance Company Name ��nj /�9YVq Workman's Comp.Policy# WU `J�J��� QQ_0 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ["Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping.. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission., A,copy of the Home Improvement Contractors.License&Construction Supervisors License is ` required. SIGNATURE• C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Inte et Files\Content:Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 KELLY ROOFING 8 RHINE ROAD YARMOUTHPORT PH 508,775 4498' MA. REG.# 128957 MA 02675 LIC.# 99167 Okelly52@comeast.net INSURED' . March 4, 2011 Proposal submitted to Mrs. Corrinne DiSabato of 1132 Bumps River Road Centerville Ma, We propose to supply all materials and labor necessary to remove and replace the existing at the address above All debris to be removed to town transfer. 8" White Aluminum drip edge to be installed on all eaves. Ice and water damage protection membrane to be installed on first three feet of eaves, in all valley areas and around all protrusions. Remainder of deck to,be covered with#15 felt paper. Limited lifetime warranty Architect.style shingle to be installed.(Color to be specified) Install Shingle Vent II Ridge Vent on complete length of Main ridge. Make any necessary repair to.all flashings. Protect all walls; windows, decks,plants and shrubs etc. during roof strip Obtaining of town permit.,. Complete clean up of site during and after completion of prof ect, including all nails. At a total cost of$8900 Payment Schedule;`50% at project start,balance upon completion. - Respectfully submitted, Oliver Kelly Proposal accepted:by, Date / ,�� /2011 If acceptable,please sign and return one copy and keep one for your records. This proposal is valid for 45 days from date above,please call to.verify thereafter: � 09 ��l?:+�:iCiSi15L'Cfe- !��fia?'isl9tfi[ari ;';1; 'Il �aii..1 vk! BuiL`,Il" RC"ul ttinns and Ntan(i:1, s icense: CS.Si_ 99167 Restricted to: RF,1A 3 .; OLIVER KELLY d *� 9 PEREGRINE LANE SOUTH YARMOUTH,MA 02664 Expiration.•9128/2011 �L\ Boara oflwlsl'mgregu`1a4o%and eandarc�fs License or.registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 128957 Board of Building Regulations and Standards One Ashburton Place Rm 1301 Expiration: 611412011 Tr# 284841 Boston,I4Ia.02108 Type: individual - Oliver Kelly Oliver Kelly ` 9 Peregrine lane , ,,` South Yarmouth,MA 02664 Administrator Not valid without signature A�i� ® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD,YYYY) 2 11 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 DOWLING&ONEIL INS AGCY INC CONTACT NAME: _ PO BOX 1990 PHONE 508 775-1620 FAX A/C No): 508 778-1218 HYANNIS, MA 02601 ' E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A: LIBERTY MUTUAL GROUP INSURED OLIVER KELLY INSURERS: 127 EVERGREEN STREET INSURERC: SOUTH YARMOUTH MA 02664 INSURER D: INSURER E: INSURER F COVERAGES CERTIFtCAT"E NUNiBER: 9248378` - -- — -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. ILTR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS POLICY NUMBER MMIDD/YYYY MM/DD GENERAL LIABILITY EACH OCCURRENCE _ $ COMMERCIAL GENERAL LIABILITY PREMISES ERENTED c nce $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL 6 ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLELIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED 8 SCHEDULED BODILY INJURY(Per accident) $ AUTOS NO OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) $ $ UMBRELLA LIAO OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ $ A WORKERS.COMPENSATION WC2-31 S-338804-020 12/28/2010 12/28/2011 we sTATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER _ _- OFFICERIMFld ER EXCLUDED?ECU7IVEa'-N I A-"-"-• -- - " ' "'--'" —""-EL:EACH ACCIDENT- $-' -" 100000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Workers Compensation Insurance:Part One of the policy applies only to the Workers'Compensation Laws of the State of MA. THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR OLIVER KELLY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF FALMOUTH THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 59 TOWN HALL SQUARE ACCORDANCE WITH THE POLICY PROVISIONS. FALMOUTH MA 02540 AUTHORIZED REPRESENTATIVE . Mll�L Jeff Eldridge ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD CERT NO.: 9248378 CLIENT CODE: 1329955 Deb Derochemont 1/6/2011 7:39:28 AM Page 1 of 1 The Commonwealth of Massachusetts Print Fort Department oflndustrialAceldents Office of Investigations `�- t 600 Washington,street � N P .t.. Boston, MA 02111 =cam- www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers AvRlicant Information (� Please Print Le�nbiy Name(Business/organizwon/bdividuai):Q L V J e Address:e6- L, N) City/State/Zip:_ A4QsJQJ`-V1A QW.! A W-W S Phone#: nDrg S02 � Are you an employer? Check the appropriate box: Type of project(required): I.2f I am a employer with .3' 4. I am a general.contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached.sheet. 7. ❑Remodeling shipand have no employees These sub-contractors have g_ ❑Demolition working for me in any capacity. employees and have workers' insurance.$ 9. El Building addition comp. [No workers'comp.insurance • required.] 5. We are a corporation and its 1011 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 12.0'Roof repairs insurance required.]t c. 152, §1(4),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 am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site infor►nadom Insurance Company Name: Lk AXi-rjA, _ Policy#or Self-ins.Lie. -6 06—Q�J Q 20 Expiration Date: [? 2'5 ' 20 l -Job Site Address:1112 LrujS Q"H'Q LqD City/State/Zip: G,_Y,,C_ �tLL 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$1,500.00 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. 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 eerd under the pains and penalties of perjury that the information provided above is true and correct. - Si ature: r 0, Date: 3 1 b Phone#: e0 3 LA u n 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.Electrigl Inspector 5.Plumbing rispector 6. Other Contact Person: Phone#: 3a The Town of Barnstable 9MAM Department of Health Safety and Environmental Services 059. P Building Division 367 Main Street,Hyannis MA 02601' Office: 508-8624038 Ralph Crossen Fax: 508-790-6230 Building Commissioner SHED REGISTRATION Location of shed(addr s) Village Property owner's name Telephone number Size of Shed Map/Parcel# d8e S nature Date Hyannis Main Street Waterfront Historic District? x Old King's Highway Historic District Commission jurisdiction?. p/ Conservation Commission(signature required) 2 �' PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg 0 GOI7G, fouryd. At AL.ArAFAC&MICAL: o�riCr: GEO r->UA/A! g&ALTY GOIe° = = NB6c'4SY CAPArTi/PY 7'WO97- .77NAV AtJ/L.a/i OL s�..+aww o.v rN�s ®c A•v i� ,c.ocgrft7 caw �� � c�oRrh � ''��' so low. ;a. .. . ®Y-L/4WO CAW rvis 770*V%/ oOr �.f,�LSL TABS t`p �Fc Ro Q, q E SURV T Gf-1N/GAG. F�L ANI4J/IVQ► /"fASa. xmogp rill puns Assessor's map and lot number................................... ,.- / �✓ / /� - ",��/ r� SewiUge Permit number .......`:............................................... 4 K f ^'] Z BAAXSTABLE. i House number ...............� ........./...`:.... ..._:r.......................... rasa pO i639, e00 TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION -FOR PERMIT TO -� /v . .......^...........` .................................................. TYPE OF CONSTRUCTION .........................:: �,bra......................................................................................... . '.. ......................19 ,. ' TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the (following information: Location .:/,,Tf :.....:.................................... Proposed Use � / / {! �/+� '. /"f/ .-�, c!?;o .../ ....................................................................... J • ZoningDistrict .....................................................................Fire District........ ...................................................... .Name of Owners lfa'+rr�ra Jfl/.7 ! �� Address7��ec��J/�/.F .... ....... .... Nameof Builder � .......................................Address .................................................................................... Name of Architect A <' ..........Address a / 1+ /n t.f2,.r .. . Number of Rooms .....................................Foundation ': ': n ... ............................................................. Exterior .,< . .....................Roofing ; �+s. "r?:c:.'.'�/:................................. r Floors r"/ ............. ......... ............. �^� � Interior ................................................ Heating .. 4,.. ............. .. . ............Plumbing......................... .!.; ....................................... Fireplace Approximate Cost 1J4(� ..........`= !'?................. .................................. ................ Definitive Plan Approved by Planning Board ________________________________19________. Area .................. Diagram of Lot and Building with Dimensions Fee .. � a SUBJECT TO APPROVAL OF BOARD OF HEALTH & R 4 1 1 q I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding rthe,above� construction. NameE: ..... �� f,, ,s....... Leo Bunn Realty Corp. A=188-134 , No .21,1.39..... Permit for Build„s' , ••........ ..........fami.ly...dwelling ........... ....................... Location 1...8�..Rive d....................... .....................Centex.vilIe.................................. Owner .Leo..Dunn .Real.ty..Corp..................... Type of Construction WL.-Freme..................... Plot .................... .. Lot ..8... .................... Permit Grted ....Mar.Qki..28..................1979 Date of Inspection 19 Date Cor pleted ......................................19 PERMIT REFUSED ............... . ................................... 19 ................. ... �. � ............ ........ ...... ./:....................... ..... .......... Approved ................................................ 19 ............................................................................... ............................................................................... THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) I M ^�c� C DATA TOWN OF BARNSTABLE Permit No. -------------------- -- t saun.n a Building Inspector Cash t0)9� c OCCUPANCY PERMIT Bond ----__ ------- No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Address Wiring Inspector Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. .................................................. 19......_» ......................................................................_................_»..»».» Building Inspector -7 *Ssesspr's map and lot number STNEHE EPTIG ME. B -Sewage Permit number ....... ......................................... COf All INF,T ALLED HN VIRIAM li 33ARISTAIME, House number ............... JE.......................... !A-ITH AFMCLE 11 STAT MAM1639. -SAN!"ARY �,GDF AND "MVvli TOWN OF BARNSTABLE BUILDING' INSPECTOR APPLICATION FOR PERMIT TO .................................... .. ......... ......................................... TYPE OF C014STRUCTION ......................... ........................................................................................ yfi .. .......... ..... ..........................19/ F ILDINGS: The undersigned hereby applies for a permit according to the following information: 6 Location .......... reC:> . . ...................................... .... . ........................................................................Proposed Use . ... ZoningDistrict ........................................................................Fire District .........e=0...................................................... . No m,e,,af Owner .........Address ...)e7- Name,]of Builder ................. .Z,Q.......................................Address ...................................................................................J Name of�Architect .j�5r./91Cl/AW ...Ar<%�.........Address /J�....... ,ozew'"? ..................... NuTb,er,'of, Ro6ms.......................2.....................................Foundation ............................................ .4 Roofing ................................................. w-eloo'0 C ........ ...............................Interior ....................................... ........Floors o.o rior ..W.� .......:J:.........Plumb ing i n g.51.�- � ......... ............... Fireplace ............ ................................................Approximate Cost .......................................... Definitive Plan Approved by Planning Board ---------------—--—-----------19--------- Area t.................. Diagram of Lot and Building with Dimensions Fee ............................. SUBJECT TO APPROVAL OF BOARD OF HEALTH 140 I hereby agree to conform to-all the Rules and Regulations of the Tow. o Barn e regarding the ove construction. No ......... ........... Colafella, Angelo 9/8/80 No ..21139... Permit for ......$uiid..single.... family..dwelling..................................... cocati4 �3umps River„Road.................... Centerville ...................... AnQelo Col.. afella ......,....... Owner ...... .......... e e Type of Construction ....Idctod..F.rame....F........... 'Plot ......... .............. Lot .....B........................ f . March 28 19 79 Permit Granted " Date of Inspection ............ .. ...�••.......... Date Completed ...............cr .` ...19 t PERMIT REFUSED ` s ...... ............................ 19 ••••.Fq{�' • .y.�.• •se.4we- •............. . . y� ............................... � ' `......................................................................... .�. ............................................................................... Approved ................................................ 19 ....................... .................... ' •_�� / 5 44000 .. ....:vs!. ............ . ...... ' t .., � .... ....:: ,,hw,.�rP:.zA < .,,,.: . ..>:q.. err.?.. ., d':.•.: r �i.b.'�::15`•46,�';1',v� I •r _ ,f; y71 y ':rtF �K,�,f tjMMTa� Fh � I ff !mil ' _S Y IL Af t4 r j 2 Y I 1 ' t ry a W6 •, f'� X �� '� +YI•2 ! t f 4 L \ I - 1 t� it A ( S L ' r L 1 41 4 � ;. ����f�l✓ ii 1� �� x �� 1, . 1 L: x Y ' � !31 r r I r - h� l a i � I r < "� �n jl '� a a.iS-• + r. + t r ,a f 4 r , t '7 1 M rr r 2 f �1 r 1� ''� 7 t rir• r r:r} a ,..Y 3'•7^' "a' 4 ; u _} �+ i .a r*f t `k':+5-' v .. it"r A $4��. id 6 t a s n, � f• sa 1 F ��� 'H P 3 t e hl�a y � ' r Y. M 1 !� �{ 41. h ^k. 1 1 � f '�1F i f ! � 1 f I x t�• t �. fte J �F # a N •es 4 r� F a ti -f f � 'd. 'd- , '�3 i �`• N k A i I - -loop t J"•' a�„�+..,,K�� f .el _r � t ` 4� �,x A � �.t..•.r�+t„y. •.,•,.,�- � ��-v.•4,y.r.�..,}�c.a �- a1F••.�*=-�nr + ��r�,rl►.-rw.�...t ..t�' 0. ..-..� ....!�.:: Y ( TIT C 111/ may, '• /++ �• `�� ( _ - [ _ a -it "ly f �i..nL•4'+�r�.+I I�.+•+ �I "r'�I �•,�.� 0. ..r} t ;l '`� ��� i 'x d Jd"s►E'+�1?F" �'e�aaT1�y� 7"1►.4r7" 7'kflF �fa�+f.��IKJ►,�" ' lr��{� � qfi� °r � I x��"'A 4f�Y1r�R q+Rf -wy,��, '7��� f•�!' `' L �; � ` -�. � '� {, V cA .� r fl,� , r t � a f r s 1 .. H� '..t ' } _• a 3 G/-II�IJ/G�L�� P� + ll�f � � z � ; /� ��• !. t '��' n r P x ,, r r. � ? Y �!•i� t ti r { r ° �� a TOWN-OF BARNSTABLE BUILDING PERMIT APPLICATION Map J' Parcel Permit# —Flesltl°r6ivisivn Date Issued Fee -r2°5-.aa Tax Collector Treasurer 614 Planning Dept. F' Date Definitive Plan Approved by Planning Board t 13r is t - Project Street Address 1132 /3�mLU�� Village F 7Ei2Ul z t Owner N5 B —To Address 3 ti Telephone Permit Request J--AJ cS'fre� C� �1525�'L /�'1 ��1 �4t L' , S 3(Q�� a < Square feet: 1st floor: existing proposed 2nd floor:existing proposed Total new Estimated Project Cost Zoning District Flood Plain Groundwater Overlay ; Construction Type_W2 1��- 3F Lot Size Grandfathered: ❑Yes 4,No If yes, attach supporting documentation. Dwelling Type: Single Family OIL Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes Olo On Old King's Highway: ❑Yes j No Basement Type: Full El Crawl ❑Walkout ❑Other "Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air: -❑Yes ❑No • Fireplaces::Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new <size Pool:❑existing ❑new size Barn:O existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial O Yes XNo If yes,site plan review# Current Use Proposed Use • BUILDER INFORMATION Name 01,E-Z ASP LL_MPIP_ Telephone Number Address &J/7)� License# OBg!Lf Home Improvement Contractor# Worker's Compensation# SKaei t ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO � DATE SIGNATURE- " r -FOR OFFICIAL USE ONLY - -� • , . . + f„- '` �• ten• �• � ^ r • •i. - • .' • i ~ - , ' • , ' - - PERMIT NO. DATE ISSUED MAP/PARCEL:NO. ADDRESS r,r, f. - •VILLAGE, t ; :..� OWNER DATE OF INSPECTION FOUNDATION ` FRAME INSULATION - FIREPLACE - - ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: - ROUGH FINAL r FINAL BUILDING + DATE CLOSED OUT _ + ASSOCIATION PLAN NO. I +5.9� � iy W ES'1 wln Wit? \r 'i163 j j •,r t w :' „ J SCALE: 1"=250' {` �' ' ;;, N, i ` 1 ' _u i aA t / , /4 ; I 1`al'Iq Nr• _ \ 'j `".. '••\I `�� ',t\ \ I i i`6? �' Y �"^ YIN .� �,',I {12r � e� \ + -- \ \ � L {+� i' 1 WI /.erla/ r,',' , +IrF � ,� t '/3 •— . .i: i/ it 1 5 'i i 6 Y +a win gp r i _�\�:•'s,s, i 1 6A �/ ,?�_ , t O , , "'i!!, t I j;•\ 's. I i i '; /D �' `Ysa ,Q .= s `�r 9 : s L p 1 Ysa/,! `\ / (I�(II I �I �\~l��• i i�A \ �• \' Ir ,''� S/ t48� �f __ Y� % 27,,l i iir`".. -••_� .N, 4s9( �\. "9 _ .: Lrs 1 µ i•--•%I t Mus4 }. -� '/�/i� ; �ta4i�: � 17�• ',�7� / ,�; e 4 Fr � '� µai II �� r' f )��r i,�`J• ` I i �{ r \1 /'ws 'T {� `' eNstl 1 r� ,-:�.:,cr. F, 1 t ASS it Iail. \ is win of • t i > ' /r '.' C: `� �a« i i { 111Z �r/"� ::.:..\ i �a i I !'r!q �/•. `.{.l { / // f ••'' I I '/r �'•` 445 ,� �Ylu/ ✓/�1 r r al*ky ( i 111 i�� 'r r I t ,`\ � /t. J +II ',i• 79 / , \ \ :i � i: ,e'er 11rrr' :n' / ;'/ r,' •It s 1 1 {: tin s•, {{ eve f y rl �: `�i.\Y^, / "\ � I \ _ Y 1 ' tll ;,; '_ 'J^34 w /f• � � 1�vy sA /S \ ?rr \ r �\� ;• Ya i _ !�! I% �•:�\ �J, o� �'' ` '��3``l`t � �,�' - '�'r��•, j�1 //� •g 1 r/{ r r 10 99 � \ �.OsS/r �;f• \i\ s4 �+ee � ) i Y r }- ( 1 ','///.rij7 z``Jr m Ann % i -� •. _.. � t s w�ti - 23•� �is 1,.:/ ••'�.r-'" �. The Commonwealth of Massachusetts Department of Industrial Accidents _ •y � .•�� � Ol1lc�ello�stlAel/OQs . b� .600 Washington Stret e 5. Boston,Mass. 02111 Workers' Comiensation Insurance davit y name: location- 3 P city nhone# /o - 7'7J— ❑ I am a ho" emmer performing all work myself. ❑ 1 am a sole proonetor and have no'one wokn inaacity // % . I am an employer providing workers'compensation for my employees working on this job. comaanv name: address: /1LeL[J71341 ill city: Co 74 i T Gato 3S phone*#: (3Or) Insurance cn. olicv# WC ` 4 1 /.W/�/�/l4l�l////////// r Y ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the follo«ing workers' compensation polices: eomoanv name: address. dtv phone#• _.... insarnnce cn. piney#.. /i/GGUU///ii /G����//vu✓/tiZz %✓/; eamnanv name: . address• citN- ......... - olicv# tuarancc co. .: :. : •: . i;&-re to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1300.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP wORIC ORDER and a Me of$100.00 a day against me. I mderstand that s copy of this statement may be forwarded to the Omce of Investigations of the DIA for coverage veniticatioa I do hereby terrify under the pains anddppen all irs perjury that the information provided above is era:and correct Date Y/� f _ Print ttatne �/e Ed Et%CK V. IRA S C H_Ia'� %Z� phone r oM7- - do not write is this area to be completed by city or town o1Dda1 dry permftNcense M QBttilding Department - -- - -- -. --_- --------- (]Licensing BoardcdLteeea b mred - --- - - —- - - --- pone req Sdedntea's OtIIuQHealth Department con • phone W. • ❑Other (mvuen 9,95 PJA) The Town of Barnstable 9 KAMM Department of Health Safety and Environmental Services 059' Building Division Fo ru3' 367 Main Street,Hyannis MA 02601 Ralph Crossen Office: 508-790-6227 Building Commissioner Fax: 508-790-6230 For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more be done by registered dwelling contractors,tso with structures which are adjacent to such residence or building certain exceptions,along with other requirements. '�� ��� S Type of Work: Est. Cost�' c-LY)S- STCC Address of Work: Owner's Date of Permit Application: I herebv certify that: Registration is not required for the following reason(s): Work excluded by law Job under S1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: UNREGISTERED OWNERS PULLING APPLI ABLE HOME OR DEALING WITH IMPROVEMENT WORK DO NOT HAVE CONTRACTORS FOR ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: D 0 Contracto Registration No. r Name Date - OR 's Name �//8C Z/IO�/7Ll)Zo'72r!/e(LGIlI- n` '(�(1'JJ(IC�CLJC�' 'RR MEN CI A,:iRU ?IDIi ;IIPFLirC,Ur: ;: Nanhercc ��ie{o�alw)nonlueal�i o�./uaaoae•/tueelLi e=_trlr(ed ?0: J�) HOME IMPROVEMENT CONTRACTOR ►" THOMAS CAP!_-- Registration 100740 i ' 645 NEW?OIJN Ri'• Type - PRIVATE CORPORATION CnTOIT, MA1f35 Expiration 06/23/00 i. _ -• - CAPIZZI HOME IMPROVEMENT, INC ]jL� Sas Capizzi, Sr. ADMINISTRATOR-'- Q Newton Rd. Cotuit MA 02635 -------_-- — ✓ire La//v/na�uveah� o/�..l/la:;Jrlclude� w DEPARTMENT Of PUBLIC SAFETY CONSTRUGT.ION SUPERVISOR LICENSE Number: Expires: Restricted To; 60 i THOMAS X tAPIZZI JR >v: �286 PERCIVAL DR 77 :I W BARNSTABLE, MA 02668 ,� ✓fie �olunzo�uuealtl n/�.-G�aa�rie�u�e�' DEPARTMENT Of PUBLIC SAFETY • 4 CONSTRUCTION SUPERVISOR LICENSE Number: Expires:/. Restricted To: 00 _ FREOERICK V RASCH iII BOURNE RD PLYMOUTH. MA 62360 I ._. _ :._—...=-x-�-^---:'.:_-..�..____ .._._.- _� .__._�.._-:.._s_-ssxr—_---=-=r._-._�._'-��y_=-_c�a=z�.=.•a-r�-�—.�.> _�. -s<_-a-s=x_=-.ter-.�.....-..--a.,a_�_.z�__ .___...r.-u�-��_�.-�_.�_�r�=:r._.b�_�_�.��_�.<,�>_-z._���-_.nm..�_.-•_ _-__ __..,c....,«.��._.. -. ..-:..., -,.,�...->.,,.-�_..�.�.v.�-.,s..�.�.�...,�.�...-.v..��.,,-�,�a.____-_�..r:,«.rwu- � `T j — j 2:D , [" G L t, tit 3 , S - t..1 r-��C�,c..� ✓✓� 2R �F� — GX 64 cfc2. Lsk t 71 9 Q," - t T DAJ g1 C> A _ ' ral T\\4 C � � I71 U 1 .. 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