HomeMy WebLinkAboutBuilding Permit #379 - 104 GREENE STREET 10/27/2011 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
I
Permit N0: Date Received
Date Issued:
IMPORTANT:Applicant must complete all items on this page
LOCATION d y 6_7 rd.
Print
PROPERTY OWNER C,o (Lo L, =,qUnit#
Print
MAP NO:3,11—PARCEL: ZONING DISTRICT: Historic District yes o
Machine Shop Village yes no
100 year-old structure yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building cKOne family
❑Addition ❑Two or more family ❑ Industrial
Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
' DWaterhed�DisS0 Wel ' F❑; ec, loodplaii q Wetlands; tncf
0 Watez/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
rYtyt.-e LA e�z w0o cA Aln
(Identification Please Type or Print Clearly)
OWNER: Name: S C_ C1 Tr-- 777AL-v 4.,^ Phone: _7
Address: Z ��v S i—
CONTRACTOR Name: �— �,�. �ti��UJ' �°. � Phone: `-t 7 "? 5
Address: &Ll�c `urzt_ 6r,-o(f [L7 1 cc ko
Supervisor's Construction License: q -7 E,_2> Exp. Date: <
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PER
MIT.$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ 00 FEE: $ 10
Check No.: G ?:> - Receipt No.:_oZ�
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
kS�ignature_ofAgentl0wner Sic
nature,oficontracto
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools El
Well ❑ Tobacco Sales ❑
Food Packaging/Sales El
Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— For department use
❑ Notified for pickup - Date
Doc:.Building Permit Revised 2011 June/mi
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of 8Idg .Permit
9
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: Doc.Building Permit Revised 2008mi
Locationw
No. _ Date
i
NaRTM TOWN OF NORTH ANDOVER
F �
A
Certificate of Occupancy $
US 9
tBuildin /Frame Permit Fee $ low
s�cNt
1 Foundation Permit Fee $
a
Other Permit Fee $
TOTAL $ •r.
Check # G3?--
2 47
7
0
Building Inspector
AORTH �
TONM of
o , dover, Mass., n sit
oLAK 6
COCHICHEWICK
ATED
qS V BOARD OF HEALTH
S- Food/Kitchen
PERMIT T D Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT.............S.eA ......S... .!^! .......:............................................... Foundation
11 4
k11
has permission to erect........ :............................. buildings on ......1Q ........
11115111.111f .. . ........ ....... ................. Rough
0.f. dtChimney
Y
.............to be occupied as.. .... ........: 41 ..
h the acce n this permit shall in eve respect conform to the terms of the application on file in Final
provided that p p g P every P
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 CONSTRUCTIO ST Rough
............. _....................................................
Service
BUILDING INSPECTOR
' Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
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.
SEE REVERSE SIDE Smoke Det.
NORTIy 9
0 of over .
O
No.
o dover, 1Vlass.,.� • �� • /t
O LAKE �.
/�. COCHICMEwICK V
ORATED P?a���
v V BOARD OF HEALTH
z, Food/Kitchen
PERMIT T D Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT............. ." ...... ... ....................................................... Foundation
has permission to erect........ :.::.......................... buildings on ......10%(....... .. ...........&4. 0404.0.0...... ................. Rough
....................................................................
to be occupied as.. ... .... ........:0jiK.4d6 ...... Chimney
that the acce n this permit shall in eve respect conform to the terms of the application on file in
provided t o p p g p nl P PP Final
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 CONSTRUCTIO ST
Rough
..................... .............. ...................................................................
Service
.. BUILDING INSPECTOR
Final
Occupancy Permit Required to Ocatpy Building GAS INSPECTOR
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.
SEE REVERSE SIDE Smoke Det.
' The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 0.2111
www.mass,gov/dia
Workers' Compensation Insurance Affidavit; Builders/Contractors/Eleetricians/Plumbers
A Iicant Infer tin Please Print Legibly
Name (Business/o rganization/Individuaq:
:-lddress: rL
.4
City/State/Zip: .. #:���..�.�..��....��_
Are you an employer?Check the appropriate box: "-
i. I am a employer with 4. ❑ I am a general contractor and I Type of project(required);
employees (full and/or part-time),* have hired the subcontractors 6' Q New construction
�•❑ 1 am a sole proprietor or partner• listod on the attached shoot, t 7. ❑Remodeling
ship and have no employees These subcontractors have 8, ❑ Demolition
working forme in any capacity. workers' comp, insurance,
[No workers' comp. insurance 5. ED We are a corporation and its 9• Building addition
required] officers have exercised their 10.0 Electrical repairs or additions
3.❑ lam a homeowner doing all work right of oxeatptiou pot MGL 11.❑Plumbing repairs or additions
myself. [No workers comp, c, 152, §1(4), andwo have no 12,[D Roof repairs
insurance requirod.J t employees. (No workers'
comp, insurance required,) 13,❑ Other_____^_ ^
',."ny applicant that chocks box#I must also fill out the section below showing their workers,'compensation policy information,
' Homrowners who submit this affidavit indicating they are doing all work and then hire oupido contractors must submit a now affidavit indicating such.
Con1racwrs that cheek this box must attached an addldonal'shoot spewing the name of the sub-eontraotors and their workers'comp,policy information,
NNNN
nut an employer that isproviding workers'ootngensatlon insurance for my employees. Below
iiVjrmation, is fire policy and)oG site
'r:surartce Company Name; V
1
Policy # or Self-ins, Lic• #; V Expiration Date:� �1
Job Sile Address: I b Lf City/State/zip:�� �� c.< �►
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration dntC).
Failure to secure coverage as required under'Section 25A of MOL c, 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisortmont,as well as civil ponalties in the form of a STOP WORK ORDER and a fuw
o f'up to$250.00 a day against the violator. Be advised that a copy of this statement may bo-forwarded to the Office of
lrtvestigations of the DIA for,iasuraneo,eoy'orage vorification,
I do hereby eerto under the pains and penalties of perJ4ry that the lVormatlon provided above!s true and currccr,
Si[�narure:
Date:
Phone#;
Oficial use only, Do not write In this area, to be completed by city or town offlcial
City or Town: Permit/License#
i Issuing Authority(circle one):
1. Board of Health 2,"Duilding Depart I mont.3.City/Town Clerk *'Electrical Inspector 5,Plumbing Inspector
G. Other p
�I
Contact Person: Phone#:
.. ... ... ........u.\ul:Jli:.[.'.:_1fa..W:aL............aa�..w.l....._..........i...�L.i...�.:•1:411�:.�_.[..... ._.. ... .. •�{'.._...:i[•:..iSt:'•Yuli lfi,.'..'Ill is.. ... .. .... .. ..
JAN-24-2011 11:27 Sennott Insurance 978 88? 2404 PW.Lf.01
L PROD)CE+ 978. 8 .4900 FAX 976.887.2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Edward F. Sennott Insurance Ayencyl Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
16 South Main Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
P. 0. Box 457 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
Topsfield, MA 01983 INSURERS AFFORDING COVERAGE NAIC9
1NJIu�O e inc i b 91 y Contract I ng .. -I nc. INSVREAA: tin C • t nsurance 0
23R Winter Street mum e: Travel ers 19038
Peabody. MA 01960 IN$~9
MISURER c
INSUREA E
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REOUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
"Y PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN lS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIM$.
TIN WC TYPE OP OWRANCE PoIIDY NUldsm UMIry
GENERAL LIABILITY MIME / ! 0 1 0 ! FACH DOMMENCE s 11000.0001
r ODMMEACIAL 080AAL LMILITY L, a i 100,000
CLAW MADE [!] CCU
OR MED OP UVd an Dwwnl i 5.
A PERSONAL i ADV INJURY 1 1 000
GENERAL AGGRBOATE S Z 000
OENL AOGREOATE LIMIT APKU PER: PRODUCTS•COMPW AGO S 2
POLICY LDC
AUTOMOiILE LOA LM - OOMBwED 91NOLE uMrT S
A►VY/WTO (F+wCWerM)
ALL OWNED AUTO&
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SCHEDULED AUTOS (PM WW)
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AND EMAYEAW LW ILRY Y J N RY
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ANY PROPRIETOR/PMRNERM(ECUTLtL EACH ACCIDENT $
OFFIC6UMEM13ER EACLUDED7 u
xvwf wy M NNI E.L.DISEASE•EA EMPLOYE 1
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$PEC IAL PR V{S LL DISEASE•POUCY LIMIT S
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DEIGWJ'TON OF 9►€RATIONS!L06ATIOIN/VE111DLEilEJtOLU�lON9 ADDED aY EIOUR8E11EMf 19PEICIAL PROVI{gN�
Evidence of insurance.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DEEORIBEO POU=3 9E CANCELUD WORE THIS 4XPWAMN
DATE THEREOF,TMC LTMUINO INSURER MU OWAVCR TO MAIL 10 DAYS YMYTTEN
NOUX TO Tm CEATIF"m mxm MAMBO To THE IA".OUT FAIW RE TO 00 90 SMALL
Evidence of T n s u r a n c e R,WO0 Nq 961LIGATION OR WWILTTY OF ANY 10ND UPON THE INSURER,ITS AGENTS OR
ANVES,
AUTHOROW IriPRESMATIVE
Robert Sennott
ACORD 25(2009/01) 019W2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are realatered marks of ACORD
'"4 w C-UI1 1J e-ti 5ennott Insurance 9'7k1 88'7 2404 P'ul
I'�V Vf%WTM vr. • , .. .y.. . �r .erNr+ &..ff SaWf I t• , .,.\I\I►�.�I'1e.�.r.w�.. 07/28/2011
PRObucER 978,887.4900 FAX 97141117;1404 TNI 4E TIF ATT!I a>f Ep S A MATTER pF INFORMATION
Edward F, Sennott Insurance Aggncy; Inc, ONLY AN CONF NQ'RIQHT>i UPON THN'CURTIFICATE
16 South Main Street MOLDER.THtS CERTIFICAT91 DOES NOT WOO,EXTEND OR
P, 0, Box 457
ALTER THE COVERAGE A FO ED BY THE POLICIES HELOW.
- I
Topsfield, MA 01983
INSURERS AFFORDING COVERAGE NAIL N
INSUREO Len Cie y ontracting Co Inc,- INsvwA A.I.M,
Z3R Winter St. --- .-. _
Peabody, MA 01960 IN6uRlRe' _._
INSURRR CI
INSVRiR 0:
NNSURlR!:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THe POLICY PERIOD INDICATED,NQTWITH$TANOING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED Ori
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES OESCRISEO HEREIN 18 05,IECT TO ALL.THE TERMS,EXCLUSION$AND CONDtTIQN$OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE.PEEN REDUI;EP gY PAID CLAIMS,
INR TYPE OF INSURANCE POLICY NUMeaR' LIMITi
GENERAL LIA016I1Y
EACH OCCURRENCE 3
COMMERCIAL GENERAL LlA91LITY ---- -
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CLAIMS MADE []OCCUR MED EXP(Airy Ong IWrw)-------------
PERSONAL 8 ADV INJURY 3
..'• •••-.�,•.' GENERAIAOGRiOATf� i
i GEN'L AGGREGATE LIMIT APPLIE6 PER: /RQpuCTE CQMi/OP 000 b
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ANY PROP MOER PACLVQe IxECUTIVEn `.L,NIAQH A09I04K i T 500100
A OFFICER!MEMBER EJV:LVOED7 1.--.1
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OwWPTIONOFOPERATION61LOOATIONDIVe/NCLi6/BXGWegNeAaP BYaNWOReSMRpTIi►iCIAIWIPVIiWNs
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CERTIFICATE HOLDER
CANCELLATION
iwip ANY OF.THO"W4 4POP PVLIQ W$Ri CANCQUW NRFW THE RXPIRAnON
DATI,TrISIleOf,Tbt IeeI11NQ Mt4.4pfR.Wli,�ENDEAVOR To AINL: PAYE WRITTEN
NMI TO TNS 999WMAT7;MOLUFA NAMED TO TN!LEFT,I9UT i.Al1.LMLE TO Do so SHALL
IMPOie No 9#49ATKNr OR 41AWUTY OF ANY KIND U?pN TNIII IN$VRER,IT$.AaEN r$OH
Re' ltCrRl�1.
Evidence of Insurance AunlOn�c� errtArive - .
ACORD zs(zoosrol) Robert°Sennott
0 2009 APPRO CORP Q"TiQ , All rights rusumd.
The ACORD name and logo are regletersd marls of ACORD
*- µ Nussachusctts Dcpurtntcnt ut'Public'S�tfct>
Buurd of Building Rivgulatiuns and Standards
Construction Supervisor License
License: CS 94763
Restricted to: 00
THOMAS R DOBBINS ,
19 CEDAR HILL DRIVEr
DANVERS, MA 01923
Expiration: 5114/2012
(bulilt l..riuner Trp: 23757
, �e '�arnnu»uueall� a�✓�aasuc�ivaell4
UI'licc of Consumer Affsirs&Business Regulation License or registration valid for individul use only
p
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
Registration Type:
100811 10 Park Plaza-Suite 5170
Expiration'..1/23/2012; Supplement Card Boston,MA 02116
i EN GIBELY CONTRACTI G Cor;INC.
THOMAS DOBBINS
149 Main Street
PeaDody, MA 01960 Undersecretary Not valid without signature
LEN GIBELY CONTRACTING CO., INC. rageIvu. DI If rages
23R Winter Street 23289
PROPOSAL
PEABODY, MASSACHUSETTS 01960
All home improvement contractors and subcontractors
(978)531-8234 Fax(978)531-9304 engaged in home Improvement contracting, unless
www.lengibelycontracting.com specifically exempt from registration by Provisions of
Chapter 142A of the general laws,must be registered
Submitted with the Commonwealth of Massachusetts. Inquiries
To: S60,4 4—carC), TCi)un k- ._ about registration and status should be made to the
Director, Home Improvement Contract Registration,
Q Y �j_/�Q(n ._ S _ One Ashburton Place, Room 1301, Boston, MA 02108
(617) 727-8598. Owners who secure their own
////n}�'� construction related permits or deal with unregistered
�I A JVV "-`�'t-Q y yf - - contractors will be excluded from the Guaranty Fund
Provision of MGL c.142A.
P ONE DATE REGISTRATION NO.
T )8I- ,5 Z.7 Z 7/Z MA.REG.100811
OB NAME/NO. /rte-- JOB LOCATION
.5.4--I
We/he,reby�submit specifications and estimates for work to be performed and materials to be used:
-3 _—
ID,4 d/2117
- 4-- .�-.s.��g e_._ _�_(--s--t_
4a,VPI -j-W 74- --
Constructionrelateddpp(enmmits: _--
WORK SCHEDULE
Contrailr egin t rk or order the materials before the third day following the signing of this Agreement,unless specified herein w i .C-t for will gin the work on or
about date).Barring delay caused by circumstances beyond Contractor's control,the work will be completed by e).The Owner hereby
ackno ges an roes the scheduling dates are approximate and that such delays that are not avoidable by the contractor shall not nsidere as violet, 1 this Agreement.
WARRANTY Q�/p�(
The Contractor warrants that the work furnished hereunder shall be free from defects in material and workmanship for a period of 1.1J..L\.,1_following completion and shall comply with
the requirements of this Agreement.In the event any defect in workmanship or materials,or damage caused by the Contractor,his subcontractors,employees or agents,is discovered within
one year after completion of any Job,including clean up,the Contractor shall,at his own expense,forthwith remedy,repair,correct,replace,or cause to be remedied,repaired,or replaced.
such damage or such defect in materials or workmanship.The foregoing warranties shall survive any inspection performed In connection with the agreed-upon work.
We Propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of:
Payment to be made as follows: dollars($r
%(s I )upon signing Contract;< e�fgdna111di1� lName of Contraegist t___��"
%(s )upon completion of _._ _.
Street Address
%($ )upon completion of
City/Slate P one%
($ )shall be made forewith upon
completion of work under this contract. Phone Eederal ID No.
Notice: No agreement for home improvement contracting work shall require a down e 1 man
payment(advance deposit)of more than one-third of the total contract price or the —
total amount of all deposits or payments which the contractor must make,in advance,
to order and/or otherwise obtain delivery of special order materials and equipment, Aut ize
whichever amount is greater ote:This proposal may be withdrawnus it not accepted within days.
Acceptance of Proposal I have read both sides of this document and accept the prices,specifications and conditions stated.I understand
that upon signing,this proposal becomes a binding contract.You are authorized to do the work as specified. Payment will be made as outlined above.
You,the Buyer,may cancel this transaction at any time prior to midnight of the third business day after the
date of this transaction.Cancellation must be done in writing.
DO NOT SIGN THIS CONTRACT IF THERE ///��AREANY BLANK SPACES. R
S,gnature Date Signature Date✓ I
IMPORTANT INFORMATION ON BACK