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Building Permit # 8/1/2016
PI ,r+e ,ORT . �pmmemmnmmmmre,.Nmmw, BUILDING pp B� I IT qy✓�,�S L 16 P I���! 0 TOWN OF NORTH i/EFt APPLICATION FOR FLAN E AMINA N _ Permit 't Date Received 40, .04ArE®W0111 Date Issued: ITS CH 5 I TANT,: Ap licant must complete all items on this 2age LOCAT1,64 ; . RPE I t Al IARC Ztl � TYPE CSF-IMPROVEMENT PROPOSED USE' ------- ------ -- - ---- Residential Non- Residential - I I New Building rte family I Addi ' i Two or more family industrial I A ration No. of units: Commercial epair, replacement Assessory Bldg ] Others: I Demolition -I Other ;I sept �".l' ell 1,Fl tl l in „` I,a [3tefr" _ (,w eg'�r1i �x Identification please Type or Print Clearly) OWNER: Nene: � -3 Phone: Address: - �j yyyy 4 CN TRrCTl w Address,-, „. ww ,. HWnt-Irniprovem,en ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. M Tl Project Cost: FEE" Cheep No.: 13 "7k Receipt No, l ko S j NOTE: Persons contracting with unregistered contractors do not have access th gu rarity fund Signature of Agent/OWner ignat re ofntr � mow� FORTH own o ndover ® � :wr to No. &91 2t _1 � _ o : ��x� h , ver, Mass, LOCNIC KE w�C� �' IL U BOARD OF HEALTH Food/Kitchen PERMIT L D Septic System THIS CERTIFIES THAT BUILDING INSPECTOR �. _ �`+ ..... Foundation has permission to erect ...................... .. buildings on .. ..... ......... . �!"�....,......,.... ................ Rough tobe occupied as ........... ..... .. .. ............ .....,...... .... .. ! ..................................... chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS C®NST TION S Rough Service ... ...... . .... ...... ............ .. Final BUILD SPECT GAS INSPECTOR Occupancy Permit Re uired to Occup-v Buildin Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. I-IOA'IE><i4 PROVEIVIENT CONTRAC:`lt PLENSE RLI AD THIS Branch Name: New England Date:11 1_�(e -_ Sold, FwnWxd ttnd butAlud by: THD At-Home Services, Inc. Branch Number: 31 d1bla The Hones Depot At-]lottne Sol-vices 908 13oston Tu€-npike,Unit 1,Shrewsbury, MA 01545 ['oil Free 877-903-3768 Federal 1D 4 7506984M);IME Lic 0 C 02439;Rl Cant.LicA 16427 C9'Lic 9I-IIC.0565522;MA Hone Inlprovemern Connnewr Reg.#126893 Installation Address: ���ll tok — City State Lip I'umb aser(s): _._...._._.�.— Work Phone: Hon I'lnone: Cell I'lt(rlle: Me Ades: (It different fron)lnstallattion Address) city m State Zip E-mail Address(to receive project coninumicadmis and Hone Depot updaates): El I DO NOT wish to receive any nuu'lcetirng enrtilS horn The IMme Depot l'ro'ect IQrt'o►'tlratirnit: Undersigned ("Customer•'}, the owners of the pr Terry located at the above installation add€mq agrees to buy, au C[TI-Il] At-HgI1n4 Services. Inc. ("The Monne Depot") agrees to furnish, deliver and arrange for the instar[[a€bort ("Instllartion") o all nnaterials described on the below and on the referenced Spec Sheet(,), all of which araf e itncorporaucd into this Co€r{tact by this reference, aalang with any appl[calAc State SuPPlement and I' went Sunnnary attached hereto and any Change Orders (cnllcr:lively, "Contract"): )ole : (Inlenml titre mro _ hoduc•ts: _ — Spec Street(,)#; I'€'a ect Anutr€nt ❑Roxaf€ng Siding Windows ( [ Insulation t L �c ❑Gutters 1 Covers err}�r)nors ❑ ���� 5 /w -- 1� — ❑Rnotrng ❑Biotin! LVi€€dtnvs ❑ Insulation _ ❑Gutters I Covers ❑Entry Doors ❑ ❑Rooting ❑Siding Wiudows — ❑ ❑Gutter;f Covers ❑Esatry Doers❑ �... _ ❑ 11 rndotl's ❑ Instr#alia7n ❑GUItetal Covers ❑Entry Doors ❑ Av,_ 3`1€nannurn 25TV F41306 of Ctu€tI act Amount dire€pon ewtrtWn of ilnls co,n�r'ael.Mrine puneina ars n ay not deposit an€ore than one-third of t he Contract urnt, Total C:oanhwet Amami $ Customer agrees that, immediately upon comptetican of the Nvork for each 1'r(rdtlC1, 06141111er will execute a Connpletion Certificate (one for each Product as defined by an indNidual Spec- SWO) and pay any baahmee due. As applicahle, each Customer under this Contract agrees to be.jointly and severally obligated atm liable.hereunder. The Home,Depot reserves the,dght to imue a Change O€der or terminate this Conumet or wq indivi at Product(,) induded herein, w its discreliotl, if The Monne Depot or its aulhoriwd service provider ddemlines that it cannot perlbru€ its obligalion.s due to a Structural prQWo n with the hm" swirfr€mental hazards such its moldasbestos or [Cad pslnl, other SMAy concerns, f�I76, Ci 1'o€'ti iar b,,,e work required to complete (lie job was uot: included in the Contract- I'—'ayment Snnimarv: The 1hynnent Sunnnnary if k?7 It included as part of this Contract, sets forth 1114 total Cgntract amount and paynletrts required for the deposits tend final paynneuts by Product(as applicable). NOT ICF TO Ci tg O1-11+R you m e eIa(OW to n co&171)Wtdy fillvd-in L(qv of (he Contruet at the U ne yOta syn, IAF)not Signa (Completion Certificate(Mote: there is one Completion Certilicaate 1br each lister! Protest :as defined by individmil Spec Sheets) befur•e work ori that.Product is Complete. ]n the event of termination of this Ct nuact, Customer agree,; to Pay Ile Hornte. Deput the costs of rinafet°iula,, labor, expenses ,.111(1 ser vices Int•€rvichd by The home Depot or Whoriz.ed Smvice Pt•a Wer thr°oaTh the date of terrtrination, l)Itt:, arrty otlne.t amounts nts set 1'or° I in this Agreement ot-allowed under applicable I'my. THE 110iVIF DEPOT 1!4AY "TI`IUTOLD 1 .11.€11.iN TS O'4 ED TO HE HOME DEP0 1' I�RONI 'FIT; DEPCGIT PA�'1VII<aNT €1R O'111JER PA�'A�I]�,P1rs say, DIq i.�Jr't`IrWFS I,IMITIN�s '111E,HOA E Df PO'P'S OIJI-ER RIME DIES FOR RF'CO N,IsRy OP SUCH ADJOUNTS, Aeee mance and Authorization. ('uslurn er agrees and understands that this Azrreerrtrc.nt is the: entire agrt:•ennent bet�Ve�c a Custoinn.ea- and The I Inane L)epot with regard to the f'raclucts and 1n5lallnt€on services and supersctics 0 13rior(%ctissions Hind it Yret.nnents, eitlrcr 'WRi or written, relating) to Said Products and hista€llation. 'l�i€is rpt remwm cmnot be assigned car annendcel e sept 1.5Y a writin�� Si��rred fav Cuslt>met annd TIIc Home De€lot. C.rtstonlcr <rcl:no�oledgcs and agrees that Customer Inas react, Luldcrslands, voluntarily '}kept, the. to€'ens of,incl has received a coley of this Agivenwm. A .r epted by; t � Submitted E3•y: I Pre-Renovation Form x NAT-19276 This form is used to document compfiance with the requirements of the Federal Lead-Based Paint Renovation,Repair and Painting Program after April 2010. _ r Customer Address Job Number(s) Dust will be minimized d4&4_� ZqA 4191"15- Or i e r OCCUPANT CONFIRMATION e �' , � • '}�F .' Pamphlet Receipt 1 " i have received a copof the lead ha y zard information �a pamphlet infor:tting me of the potential risk of the lead M. hazard exposure from renovation activity to be performed in my dwelling unit. I received this pamphlet before vrorK began, ;tea Home Year Built Enter the year my home was buift. ` 1� If the year your home was built is Pre-197$.all work will be done following€ead safe work practices. Work area will be cleaned up Printed Name o'On:er-occupantthoroughly # I o Sig: tura of Cer!rf-r5g Lead Pamphlet belivery SEE STATE SPECIFIC FORINTS ON REVERSE SIDE 77ae Comrnonwealilt of Massachusetts Dep(zr"ent of Industr'ialAccidents (J Office of InvC',5'tigatiotu " d 1 Can�arass Street, Suite 100 Boston, U402114-2017 www.mass.govldia I tlaritets' Catraperaaatiutr insurance A Rdavit: Builders!Con ractarslEiectriciansli'lu�abers Please Print Le 'b lieant ynftirukation ala= (Tiusinesslor�3niaati.orvindivicival}: f � Ji l/ Cc) � .L Address: Cit�jl5tatelZi tom, rj J Poiae#: Are you an employer" Check the ap ropriate box: F7. e of project(required): 4, 1 arra a general contractor and I iQ New construction 1.Q i a.m.a employer wilfi have hired the sub-contractors employees (full.and/or part-time).* listed on the attached sheet ❑Remodeling 2.Q 1 am a sole proprietor or partner- These sub-contractors have Q Demolition ship and have no employees employees and have workers' Q Building addition wor!ang for me in an■/capacity. camp. ins ranco.t[Noworkers' comp. iusnranco 3 ❑ We are a corporation and its ❑Electrical repairs or additions required.] , officers have exercised their 1 j,[]Plumbaag repairs or additions 3.Q 1 am a laameovr❑ar dog;alt wcLz right of exemption per 1viGL 1�,Q Rco pairs myself. [No workers' comp. c. is?, §t(4),and we have no P7 insurance regttir'cd.] t l3. Dtl�er employees. [�Jo workers' Il comp. injut'ance raquired.] CY •su y sppli W ant her checks box 4l must also 611 out the sera doinon gow work and then hire outside Uuwactara must suhmit a ne'x 3iTdavit mdicaring;uch_ t Homeo9MCES who submitthis affidavit indicating they g tcontractors that dieck this box must attached an additiaual street showing the name of tho sub-contractors and state whether or out th a entities ave employees. If the suh-cntractors have employees,they mast provide their workers'comp poficy awnben I am vlding an employer that is praworkers'compensation Ars71rartce for my er►epIayees. below is the padicy and Job site information. I _ - Insurance Company Name: ✓. ! Policy# or Self-ins. Lic. #: Expiration 4atCitylState/ZJob Site Address:attach a copy of the workers' compensation policy declaration page(showing the pokeexpiral ation aloes of a I L c. 152 can ad to the Failure to secure coverage as and/or one required ear irn risouut nt, as well aslc�itvil penalties in the form oaf aosition STOP WORKO ORDER and a fine f fine up to$],500.00 an Y p of up to$250.00 a day age the violator. Be advised Haat a copy of this statement tray be forwarded to the Office Of Investigations of the DIA for insurance coverage verification. t Ido her ce r ain d eel e u th the information provided above is true and correct y r7 t pp esofP '7 Date: i Si e: Phone#: D C� �J L ✓'� i t officlal use only. Do not write hir this area, to be completed by city or town official. 1 I'erCnitt�.iCe1a3C # I City or Town' Issuing Authority(circle one): CirylTown Clerk 4. Electrical Inspeckor 5.Plumbing Inspector 1. Board of Health 2. 'Building Department 3. fi.Other contact Person: Phone#: c AC"R" CERTIFICATE OF LIABILITY INSURANCE D02f24f2016DmvYl 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) trust 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 MARSH USA,INC. NAME: TWO ALLIANCE CENTER PHC N o FAX No): 3560 LENOX ROAD,SUITE 2400 -MAIL ATLANTA,GA 30326 ADDRESS: INSURERS AFFORDING COVERAGE NAIC4 100492-HomeD-GAW`-16-17 INSURER A;Steadfast Insurance Company 26387 INSURED INSURER 13:Zurich American Insurance Co 16535 THE HOME DEPOT,INC. HOME DEPOT U.S.A.,INC. INSURER C:New Hampshire Ins Co 23841 2455 PACES FERRY ROAD,NW INSURER D:Illinois Nalional Insurance Company 23817 BUILDING C-20 ATLANTA,GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003741310-08 REVISION NUMBER:O 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 NTH 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 AO L 5 BR POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY CLO4887714-06 03/0112016 03101/2017 EACH OCCURRENCE= $ 9,000,000 AMACLAIMS-MADE OCCUR PREMIS£s II-1111 -111 oNcur erre $ 1,000,000 UWTS OF POLICY XS MED EXP(Any one person) $ EXCLUDED OF SIR:$1 M PER OCC PERSONAL&ADV INJURY $ 9,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 9,000,000 X POLICY 11J�T 1-1 LOC PRODUCTS-COMPIOP AGG $ 9,000,000 OTHER: 1 1 $ 8 AUTOMOBILE LIABILITY BAP 2938863-13 03101/2016 03101/2017 CoMBINED SINGLE LIMIT $ 9 000000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Per accident S UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ C WORKERS COMPENSATION WC015519215(AOS) 03101/2616 03101/2017 X STATUTE ER AND EMPLOYERS'LIABILITY C YIN WC015519217 AN,I(Y,NH,NJ,VT 03!0112016 03!0112017 ANY PROPRIETORh'ARTNERlEXECUTIVE ( ) E.L.EACH ACCIDENT $ 1,006,000 D OFFICERIMEMBER EXCLUDED? [N] N I A (Mandafory In NH) WC015519216(FL) 03/6112616 03/01/2017 E.L.DISEASE-EA EMPLOYE9 S 1,600,600 If yes,describe under Contnued on Additional Pae 1,000,000 DESCRIPTION OF OPERATIONS below g E,L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS!LOCATIONS f VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 16000SGOODST, THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER,MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. ManashiMukherjee _:IVi-r� 6_�L O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD AC RQ® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDRIYYtf1'► 07!21!2018 THIS CERTIFICATE IS ISSUED AS A(HATTER,OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICA E HOLDER. IS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED Y THE POLI S BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURE S), AUTHOR D REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(iss)must be endorsed, If SUBROGATION ISA" D,subjeal to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not onfer rights to he certificate holder in lieu of such endorsement(s). I ICONT PRODUCER NAME�CT: _Maryellen Goodwin DAVID E.ZELLER INSURANCE AGENCY INC g(,_N ,FE (781)595-2071 r(wc No)� E-MAIL ma ellen ADORess: ry _Qdavidzeller.Com 370LYNNWAY INSURE RtS)AFFORDINGCOVERAG£ NAE N LYNN MA01901 INSURERA: TRAVELERS INDEMNITY CO OF AMERICA 256J6 INSURED INSURERS: ROBICCO INC INSURERC: INSURER D 172 WHALERS LANE INSURERS: w.... SALEM MA 01970 1 INSURER F; COVERAGES CERTIFICATE NUMBER. 70815 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR HE POLICY PER OD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESP CT TO WHICH JHIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED 13Y THE POLICIES DESCRIBED HEREIN IS SUBJECT 10 ALL THE TE S, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. J kN9R LTR TYPE 0P.1N8URAHCE ADDL SUBR �pOLICYNUMBER POLICY EFF fPOUcY EXP L COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE�E TO RENTED S CLAIMS-MADE ❑OCCUR PREMISES Eaowurrarrca $ MED EXP W, ona person) $ d NIA PERSONAL&APV INJURY l $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s ] POLICY D JJEECT F LOC PRODUCTS-COMNOPAG0 $ OTHER, _ S AUTOMOBILE LtABILrrY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Par person) S ALL OWNED SCHEDULED AUTOS AUTOS NIA BODILY INJURY{Per acdden S .i NON-OWNED PROPFRTYDAMAGE i 8 HIREDAUTOS AUTOS Per-aoeidant) $ UMBRELLALIAS OCCUR EACH OCCURRENCE I 5 EXCESS LIABCLAJP S MADF NIA AGGREGATE S DED RETENTION S WORKERS COMPENSATION PER OTH-! ANDEMPLOYERS'L.IABILnY ANYPROPRIFTORIPARTNER/E.£CUTIVE YIN E.L.EACH ACCIDENT ° $ 1,0017,000 I A OFFICERIMEMDEREXCLUDE07 NIA wA NIA 6HUB5B37400216 07/23!2016 07!2312017 IMandatory In NH) E.L.DISEASE-FA EMPtO4 S 1,0017,004 _ II yges,dexhba under DESGRIPTION OP GP RATIONS Below I E.L.DISEASE-POLICY LIM S 1,000,000 -' I NIA k DESCRIPTION OF OPERATIONS 1 LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) I _ Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B.no aulhorizatl n is given to pad claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the abovelicy precedes Ike issue date of this CeMGate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Covorage Verification Search tool at www.mass-govllwd/workers-compensationlinvestigations/. ; CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BRE THE EXPIRATION DA'Z'E THEREOF, NOTICE WILL BE DELIVERED IN THD At-Home Services Inc and The Home Depot ACCORDANCE WITH THE POLICY PROVISIONS. 269 Cumberland Parkway AUTHOHIZFD REPRESENTATVkM 1 I Atlanta GA 30338 Daniel M.Crayay,CPCU,Vice President—Residual M 3rket--WCRIB OA ©1988 2014 ACORD CORPORATION All rights r ' rVed. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD ) f` RC)BERT POCZOEU 172 WHALERS .ANE SALEM MA 01970 02108f2098 JEW Co TL— Mi D �x HONIH- -V -{a?] ALL ONE 2��4� �U��r�3�'i!A ID a ATLANTA, GA 33339 l a,�dI�C'a3 lad r ItUFTI 'mir'i riana 'or oda`" 71Last Cary! —Iasi�r_��isira ioa p nff'or.adi ridli li3�t i,, flee ,4 =�asla,�r '��t'Qr9:h.. .Yairz:i]a dl:�. [f_a�rld ��1�11�li'71�?al�sf�i�l��i�i��..i .��[ 1�. S]'�i.1C�'3C�.�3�1iS1;n�rAx.alC3 11d.�i1�iS?'�� =1 —•�-�' �!?''• _] ?l.'sr?laTa-Soli:.�'_7�] "3 131 ;,,pc= 1 a 3a3eaa. L�7�L i A HOIME 3 ��J:IGES tPl�� f oz:POT a i�f[)4ti�iS ��r',C3 %� C -HARD FALLONE '0 DU LAI Nt 4nlidw11 ait it;natur. j,,M,GA 30339 f nderseer�lary