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Building Permit #403 - 216 RALEIGH TAVERN LANE 11/15/2006
TOWN OF NORTH ANDOVER NORTh APPLICATION FOR PLAN EXAMINATION OF t���o 6 y0 ti qPermitNO: �� Date Received Date Issued: r - ACHUS���� IMPORTANT: Applicant must complete all items on this page LOCATION a I& CC I�IGG'1 �CCU�r��lI� l� � �.PROPERTY OWNER � rQP't - Print MAP NO.: PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED_ USE Reside 'a Non-Residential ❑New Building ?6ne family ❑ Addition ❑Two or more family ❑ Industrial ❑ A ration No. of units: epair, replacement ❑Assessory Bldg ❑Commercial ❑ Demolition ❑Moving(relocation) ❑ Other ❑ Others: ❑ Foundation only DESCRIPTION W RK TO B FORIVIE A)o kuelvac-,f Identification Please Ty r Print Clearly) (,�G OWNER: Name: Phone(�7,:PMOQO -3 [ C4 Address: a1 RD-If,[ !clJ�v'� 4am CONTRACTOR Name: 7ohn u--Jl °� Phone: ��l vg'�C � Address: C� H° 'y ro 1014 Supervisor's Construction License: 07gv,6 1 Exp. Date: :5 -9-(07 I Home Improvement License: (7 Q pl Exp. Date: ARCHITECT/ENGINEER Name: Phone: Address: Reg.No. FEE SCHEDULE:BULDING PERMIT:$12.00,PER ER$1000.00 OF THE TOTAL ESTIMA TER CO T BASED ON$125.00 PER S.F. Total Project Cost :$ a FEES Check No.: _Receipt No.: Page I of 4 TYPE OF SEWERAGE DISPOSAL Swimming Pools ❑ ❑ Tanning/Massage/Body Art ❑ g Public Sewer ❑ Tobacco Sales Food Packaging/Sales ❑ Well ❑ Permanent Dumpster on Site ❑ Private(septic tank,etc. ❑ Electric Meter location to project T I NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund IIr l Signature of Agent/Owner Signature of contractorC/_?- dr(.z Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF-U FORM t i - DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ []Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other i COMMENTS ; j DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED ,HEALTH ❑ ❑ y ,,COMMENTS i t Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer connection/Signature& Date Drivewav Permit Temp Dumpster on site yes no Fire Department signature/date I i I Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides. Required Provided Dimension Number of Stories: Total square feet of floor area,based on Exterior dimensions. Total land area, sq. ft.: NOTES and DATA—(For department use) I i i i I EJMC. I . I NAL SERVICES DEPARTMENT:BPFORM05 6 E 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 Addition Or Decks ❑ Building Permit Application ❑ Surveyed Plot Plan ❑ Workers Comp Affidavit i ❑ 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) 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 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:INSPECTIONAL SERVICES DEPARTMENTMFORM05 I PauP 4 of 4 Location K,& No. Date �aRTM TOWN OF NORTH ANDOVER ►. 9 t Certificate of Occupancy $ �'ss�cMusE�t� Building/Frame Permit Fee $ �' Foundation Permit Fee $ Other Permit Fee $ r. TOTAL $ Check # a >�s 19810 �' Building Inspector N®RTH TO" Of g over .rrr•V'NrT'u ..Yr;M No. Air . 40 o E dover, Mass., COCHICKEWICK RATED `s BOARD OF HEALTH PERMIT T Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT A.. .............4-10 -.4.. ......................... ................... Foundation � has permission to erect........................................ buildings an p;1�........ ..i(�. �.....rd.010%... .4#,.s Rough to be accupied as M►� .. R•o�� "Off Chimney .... .... ................... .......... ....... .... .. ... ........... .......................................................................... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in 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 PERMIT EXPIRES IN V MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRU O ST TS 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. renewal- BY ANDERSEN'--.Nrd—l'tomemr 104 Otis St.-Northborough,MA 01532'Main:(508)919-0900•Fax:(508)919-0903 J&L Windows,Inc.dba Renewal by Andersen-Contractor License#144318•Expiration Date 09/23/2006 NDOW/DOOR CONTRACT J SOLD TO: ;� n J ! DATE: /U U Q ADDRESS:f Gaho Rf4L10 AJQrP L0 PHONE-Home: 76 � i5 CITY:�o;la STATE:MZIP: PHONE-Work: (_) JOB SITE ADDRESS(if different): ` r� Approximate Start Date: �-V 1�PB/L S Approximate Completion Date: o[` jQ2c,5 SPECIFICATIONS Renewal by Andersen..Approved materials will be furnished and installed to these specifications: a l 1. Install total of: windows. Install total of: doors. antity of windows: �f�'' oil, f 2 QuIfDouble Hung(DB) Equal sash ❑Cottage sash(1/3 top,2/3 bottom) ❑Oriel sash(2/3 top,1/3 bottom) Casement(CW) ❑Hinge right ❑Hinge left(as viewed from exterior) _Double Casement(CDW) Casement/Picture/Casement(CPW) ❑1:1:1 or ❑1:2:1 Gliding Window(GW) Glider/Picture/Glider(GPW) 111:11 or 111:21 _Awning Window(AW) _ Picture Window(PW) Bow Window 3. Lfryes ❑No #Windows to be Insert:_ ❑Insert(Int. xt.casings/sill remain) ❑Insert(existing casings and/or sills modified-give details on line 24) 4. ❑Yes Windows to be Full frame(includes new interior&exterior casings): Exterior casings: lne ❑Maintenance-free material ❑Factory applied 408 Fibrex brickmold 5. Glazing to be: kn HiglhPP�formance ❑Other If other,please specify: 6. Exterior color to be: ee ❑Sand ❑Canvas ❑Terratone 7. Interior color to be: 12 White ❑Sand ❑Canvas ❑Terratone ❑Wood Note:Interior color can only be white,wood or same color as exterior. Note:Wood*nt 'or is unfinished and needs to be stained or painted by homeowner. 8. Hardware: ;White ❑Stone ❑Brass Double Hung: Install lifts? ❑Yes ❑No Casements'Z Standard Handle ❑Metro Handle 9. 0 Yes OF l�Removal of metal frames or grilles #of Units: 10. ❑Yes No Install new paint or stain-ready casings. Inside or outside stops#of openings: Interior casigrWifof openings: Exterior casings: ❑Pine ❑Maintenance free material 11. ❑Yes No Wrap exte�cawith aluminum coil stock: color, Note:Required with stormmoval.Removal of storm windoows��eave screw holes in casing. .12. New windows to have: Full screens Sf ns to be: ISFiberglass ❑Aluminum 13.Windows to have grilles: ❑Yes ❑No If Yes: Nt Grille Between Glass(GBG) ❑Removable Interior Wood(INTW) ❑Full Divided Light(FDL) Grille pattems: DH DH DH DH CW/Picture Glider CPW or GPW d '' 'use anal sheet if needed Customer approved(initials): 14. Y-e No insulate,caulk and seal windows with three-point system to prevent water and air infiltration. We 15. s ❑No Remove and dispose of existing windows and storm windows.,. 16. Install Gliding Patio Door: 11Yes ❑No Frenchwood Hinged Patio Door: ❑Yes ❑No 1160"x 68" ❑Other: Size: ❑Frenchwood ❑Narrowline ❑PermaShield Hinge: ❑left ❑right(as viewed from ext.) Op.panel is❑left ❑right(as viewed from ext.) Hardware: etro ❑White ❑Stone ❑Bright Brass ❑Other-Specify 17. ❑.Yes N stall Entry Door(double bored). Model#: Hardware: 18. ❑Y No Install storm door. Model#: 19. YY ❑No Clean Up. All job related debris removed.Vacuum nightly. 20. Y No Insurance. All workers compensation and liability insurance maintained. 21. 2'7.0ii ❑No Warranty.Given to customer upon completion and receipt of full payment. 22. Ines ❑No All discounts have been applied. / f 23.Additional information: p Cy$ i"r\ (,t.,1,i( F4 V ui J 24.Work not to be done: 25.Tlota4°1' ctAmount:$ 26. L?Yp-D No Financed. If Yes,Amount Financed:$ (Account#: ) 27. rt§_O No Customer agrees to be present on the final day of installation for final inspection and to deliver final payment. 28. No Homeowner gives RBA approval to place a yard sign on their lawn at the time of measure.All referrals given to RBA by homeowner will qualify for the RBA Refer&Reward Program. •RENEWAL BY ANDERSEN"IS NOT RESPONSIBLE FOR ANY EXISTING SECURITY SYSTEMS. PLEASE REMOVE ALL SHADES,VERTICALS, BLINDS,CURTAINS,DRAPES OR WINDOW MOUNTED AIR CONDITIONERS,AND ANY FURNITURE AT LEAST SIX FEET AWAY FROM WINDOWS AND DOORS PRIOR TO THE INSTALLATION OF YOUR NEW WINDOWS.INSTALLERS ARE NOT RESPONSIBLE FOR THE REMOVAL OR INSTALLATION OF THESE TYPES OF ITEMS. 'SALESMAN HAS NO AUTHORIZATION TO CHANGE ANY ITEMS OR MAKE ANY REPRESENTATIONS OTHER THAN CONTAINED IN THIS AGREEMENT AND"OWNER"REPRESENTS THAT NONE HAVE BEEN MADE TO,OR RELIED UPON BY'OWNER."YOU ARE ENTITLED TO A COMPLETELY FILLED IN DUPLICATE OF THIS AGREEMENT.*CONTRACT SUBJECT TO FINAL INSPECTION BY RENEWAL BY ANDERSEN CONSTRUCTION DEPARTMENT.'TERMS AND CONDITIONS THAT GOVERN THIS CONTRACT ARE PRINTED ON THE REVERSE SIDE. TTIs contract Is a legal document.Your Renewal by Andersen products will be especially matle-to-ortler for you.SZNDER NO CIRCUMSTANCES WILL R VI ION OR AN I TIONS POSCIAI F BEYOND THE THIRD BUSINESS DAY AFTER H CONTRA T HAS EN SI N AN POSIT PAID.BY I NIG W Y R ACKNOWLEDGING H THE ABOV P CIFI ATI N F R THE R A PR T Y RD ING ORRE L RbA Rep.Signature: v Date: Customer Signature: ustomer Signature: White–Renewal by Andersen Yellow–Installation Pink-Homeowner The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston,AM 02111 www mass.gov/dia Workers'.Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): P�aocd 11�A 40"et, Address:� �-1 City/State/Zip: Phone #: f ) C//9-e g00 AWY, u an employer?Check the-appropriate box:. Type of project(required): 1. am a employer with © 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.F-1I am a sole proprietor or partner- listed on.the attached sheet. $ [ emodeiing ship and have no employees - These sub-contractors have 8. ❑ Demolition working for me in any capacity.. workers' comp. insurance. 9. .❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its. required.] 10.[:1 Electrical repairs or additions> ` � officers have exercised their 3.❑ i am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers'comp. c. 152,.§;1(4),and we have no, 12.❑Roof repairs insurance required.] t employees. [No workers' camp.insurance required.] 13.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their woikers'compensation policy information: t Homeowners who submit this affidavit indicatink 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 their workers'camp.policy information. I am-an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. P. nn ) "�'� Insurance Company Name: U //[(�I .P�1 e-- 1 Policy#or Self-ins.Lic. #: (��`T Expiration Date: Job Site Address: O.1 t t-Cl� L� City/State/Zip: d�'/''lFf'1.C;�(1r et" M14 Attach a copy of the workers' com sa'on 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 ce unde t e pains and penalties of perjury that the information Provided /above is true and.correct Si .attire: - 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.PIumbing Inspector 6. Other Contact Person: Phone#c i 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'tru tee of an individual,partnership; association orother legal entity,employing'employees `However.the _. 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 employs persons to do maintenance, construction or repair work on such•dwelling house . or on the grounds or building appurtenant thereto shall.not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local 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 necessaryY.,supply sub-contractor(s)name(s), address(es)and phone nurriber(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 maybe 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 linea - 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 maybe 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 burn 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-MASSAFE Fax#617-727-7749. j Revised 5-26-05 www.mass.gov/dia f 072 ��dlQ� o�✓uaaoaaEuaell BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR NumbekCS� 074251 Bir1 — 963 7 (f167 Tr.no: 8556.0 Re JOHN K ESLERf� 78 TURNPIKE WESTBORO, MA 01 commisslorierJ . Board of Building Reeulacion3 and Standards License or registration valid for individu.l use only NOME i(it➢jtOVEMENT CONTRACTOR before the expiration date, if found return to: :..,`•. Board of Building Regulations and Standards :.;14960 One Ashburton place Rm 1301. 4Boston, a, 02109 i.1.a.Ii[pr14liD =t..1'l /2008 M } = vate Corporation RENEWAL BY', JOHN ESLER 76 TURNPIKE ROA<3 '_;%'"' �y�. .✓ WESTBORO, MA 01581kdrniniitnlor Not valid Without signature AMP-RD. CERTIFICATE OF LIABILITY INSURANCE °09/12/2006 rRooucER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Joseph MCKeone ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE JP McKeone Insurance Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 333 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, Ann Arbor, MI 48106-0333 INSURERS AFFORDING COVERAGE NAIC It Renewal by Anderson INSURER A: He rd In3urancefompany J&L Windows, Inc. INSURER B: 104 Otis St INSURER C. Northborough, MA 01532 INSURER D: INSURER E: COVERAGES 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 CI'RTIFICATE 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,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I ZAL POLICY NUMBER POLICY EFf cr" POLICY EXPIRATIUMAKEL_ DATE ON B GENERAL LLA�ILITY LMITf HER8858850 9/7/06. 9/7/07 EACH OCCURRENCE : COMMERCIAL.GENERAL LIABILITY UAMAGE TO RENTED i 1 CLAIMS MAGE ®OCCUR PREWSES(Es n0� 00,000 MED EXP MY or* ) I ---1 Q 0m PERSONAL&ADV INJURY S 1 GENERAL AGGREGATE Is 2.0W.000 GEN/AGfJREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG i Z 00O POLICY PRO- LOC A IAuTONOBILELABLLJTY 35 MCC XD 6388 10/1/05 10/1/07 AWAUTo COMBINEDEI'INGLELIMIT i 1,000,000 X ALL OWNED AUTOS" SCHEDULED AUTOS 90D0.Y INJURYnonl = (P�r Pra HIRED AUTOS NONOWNEDAUTOS BODILY INJURY i (Mf aald�M) PROPERTY DAMAGE i (Pv aodd�M) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN EA ACC f �AUTOONLY.' AGG i ETCESSAAIBRELLA LYUtLITY EACH OCCURRENCE Is OCCUR FICLAWS MADE AGGREGATE $ i DEDUCTIBLE i RETENTION f i A w,R,OMPfKi""OH� 35 WBGNC8861 1/1106 1/1/07 X ST H- ANI PROPRETWLRARTNER/EXECUTIVE E.L.EACH ACCIDENT f 500,000 O'7-C1' IMEMBER EXCLUDED7 tl dM411* � El,DISEASE.EA EMPLOYEE .i 0 SPEC PROM allow E.I.DISEASE-POLICY LIMIT i OTHER DESCRIPTION OF OPERATIONJI I LOCATIONS I VEHI LES I ERCLU31OI3 ADDED BY ENDORSEMENT I SPECIAL PROYMIONSL CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF TME ABOVE MCOND POLICES BE CANCELLED BEFORE THE EA►IRAVON INSURED COPY DATE THEREOF,THE tsimNG 04UPAR WL.L ENDEAVOR TO MAIL 10 DAYS VOITTEN NOTICE TO THE CERTIFICATE HOLDER NAILED TO THE LEFT.BUT FAILURE TO 00 SO SMALL "ILOBLN311TION OR LIABILITY Of ANY KNO THE INSURER,ITS AGENT1 OR EPREi ATNEi . AU REPREgNT ACORD 25(2001/08) m ACO ORATION 1988 re al �', xietiloaiteex d WoodNinyl Composite Frame liir _„aaia° a_ Dual Argon Low E 11��171� Double Hung -1, •1=a or((I.S)/1-P Solar Heat Gain Coefficient 1131is 330 ■ 30 Ntisible Tran;mittance IL FNFRGY STAR' ttoesaae umanna�e Quallfled In All 50 States OL 1+-- L.C 2 5 100-00231319-001