HomeMy WebLinkAboutBuilding Permit #736 - 2201 SALEM STREET 5/10/2007BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
Or i
DESCRIPTION OF WORK TO BE PREFORMED:
P l.r4e
OW67 C) O I M y 0 COP, C4.)177-4 /V0W L�rv7nay Z)cv /2
Identification Please Type or Print Clearly)
OWNER: Name: 2SM�±= Phone:
Arm racC'
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.
00
2aCQ r
Total Project Cost: $ FEE:
Check No.: ,toe. ®/ Receipt No.:4'q
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
1-1
e1
Plans Submitted ❑ Plans Waived ❑
Certified Plot Plan [I Stamped PI,
TYPE OF SEWERAGE DISPOSAL
Public Sewer ElTanning/Massage/Body
Art E]
Swimming Pools
Well ❑
Tobacco Sales ❑
Food Packaging/,Sales,-', L .
Private (septic tank, etc. ❑
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED
x
u
U
DATE APPROVED
0
DATE REJECTED DATE APPROVED
A
DATE REJECTED DATE APPROVED
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
Located at 384 Osgo� Street
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
Doe.Building Permit Revised 2007
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 Bldg Permit
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
Doe: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2007
Location
NO. i Date
7��� TOWN OF NORTHAMDOVER
Check # /0 s r
i
2D"i 99`
{Building Inspector
Certificate of Occupancy
$
NUsE<�
Building/Frame Permit Fee
$�` j
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Check # /0 s r
i
2D"i 99`
{Building Inspector
+ Alwee
982 A & A SERVICES, INC.
/& VIC 115 NORTH STREET, SALEM, MA 01970
Min 112411 PTOVINW011111111111 1111 Telephone: (978) 741-0424 Fax: (978) 741-2012
Contractor Registration No. 101609
Federal EIN: 04-3090162 Construction Supervisor No. CS057733
ENTRY DOOR SPECIFICATION SHEET
Name
<:'-e1'za- -r: 3,-cx`9 I `( - (o - 03" 1
Buyer(s) Street Address, City, State and Zip Code
-
ZZ6 1 55ALVrv( .5T Non,7H AwDevt;l2 MA OI StfS
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E -Mail Address
j'(76 -(1.S -V-8680 478-&,83 - 57epll
The Buyer(s) listed above hereby jointly and severally agree to purchase the goods and/or services listed below, in accordance with the prices and terms described on
this Specification sheet and the front and the reverse of the accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT, of which this Specification
Sheet is a part.
ENTRY DOOR
X Remove and dispose of # ' existing entry door units.
'Install new entry doors # l ManufacturerZ/✓tA
Location
Type: ❑ Steel VmoothStar ❑ Fiberclassic ❑ ClassicCraft ❑ Sliding Patio Door ❑ French Hinged Patio Door
Model # 8 �'� Sidelight(s) # 2 Sidelight(s) type/model # 72 SL A ] I)
OPTIONS:
adjustable threshold for ThermaTru Door ❑ Grids for patio doors: Style:
N Stain Kit: Supplied to owner
❑ Expand or shrink the size of the opening Details
❑ Cover exterior trim with aluminum coil stock: Style Color
Hardware: ❑ Handelset ❑ Deadbolt ❑ Footbolt ❑ Mail Slot ❑ Peepsite
❑ Install oak strip at floor as needed. —j-Hurlt Lw >-GH -t— p� a01i� C 13L44G K)
0 Caulk Interior and exterior edges.
Insulate around new door unit where possible.
< Painting is not included.
KIncluded in this proposal are set up and clean up.
!:IJ. a84
.fit
❑ Remove and dispose of #
❑ Install new storm doors #
Style .
❑ Location:
existing storm door(s).
Manufacturer
Color" Type: ❑ Aluminum " ❑ Solid Core
SPECIAL INSTRUCTIONS:
e ; I N 5 rA i.L 1-I t w A col I P OrAr o a 0--Srv�
It Is agreed and understood by and between the parties that this Specification Sheet, along with the CUSTOM REMODELING AND IMPROVEMENT AGREEMENT, consti-
tutes the entire understanding between the parties, and there are no verbal understandings changing or modifying any of the terns. This contract may not be changed
or Its terms modified or varied in any way unless such changes are In writing and signed by both the Suyer(s) and the Contractor. Buyer(s) hereby acknowledge that
Buyer(s) has read this Specification Sheet / r�
Contractor Initials: � Date: (D r 07- Buyer's Initials: lP/� Date:
I
AGrade
Above
ncel
A & A SERVICES, INC.
CES 115 NORTH STREET, SALEM, MA 01970
Telephone: (978) 741-0424 Fax: (978) 741-2012
Contractor Registration No. 101609
Federal EIN: 04-3090162 Construction Supervisor No. CS057733
CUSTOM REMODELING AND IMPROVEMENT AGREEMENT
Buyer(s) Name Date of Contract
CQrLl + BARTor)
Buyer(s) Street Street Address, City, State and Zip Code
Fi2-01 -SAIAFW ST /UonaN 14,vD0VUy1- INA 018VS—
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E -Mail Address:
a78-�s6- 8888 q78- (e,g3 -Sb it
The Buyer(s) listed above hereby jointly and severally agree to purchase the goods and/or services listed on the accompanying specification sheets, in accordance with
the prices and terms described on the front apd the Teverse of this agreement and any specification sheets (this 'Agreement"), and Buyer(s) have requested that such
goods or services be installed or provided at, Buyer's address listed above. A&A Services, Inc. ('Contractor'), hereby agrees to install or cause to be installed the products
or services listed in this Agreement at the Buyer(s) address written above. This Agreement represents a cash sale ofgoodsand services. The Buyer(s) agree to pay in
wm, u, . — guuua ... v— pm iu� cern , reyamress ui unnng ur approver or any unancmg ouyerts) may seek nor their pumnase.
G
Purchase Price: SZ Est. Starting Date: -
Down Payment: ! Z 817, Est. Completion Date:
QC
Amount Due on Start of Job: B°Check
❑ Credit Card
Amount due on of Completion: No.
Amount Due on of Completion: Expiration Date:
Balance Due on Upon Completion: a&f CVC Code:
It is agreed and understood by and between the parties that this Agreement, front and back and any addendum, constitute the entire
understanding between the parties, and there are no verbal understandings changing or modifying any of the terms of this Agreement.
Buyer(s) hereby acknowledge that Buyer(s) has read the front and the reverse of this Agreement and has received a completed, signed
and dated copy of this Agreement, including the two attached Notice of Cancellation forms, on the date first written above. Buyer(s) also
(1) acknowledge that they were orally informed of their right to cancel this transaction; and (11) request that they be contacted via their
telephone numbers or e-mail, as listed above, in the event Contractor believes Buyer(s) would be Interested in any additional quality
products or services of Contractor. DO NOT SIGN THIS CONTRACT IF IT CONTAINS ANY BLANK SPACES.
A&A Services, Inc` �'l, /r Buyer � l�
By: LCr
Signature Signature
Print Name Print Name �1
)C ES[:CiG,1 � ArLT o v
Signature
>Q 9a.,
Print Name
You, the Buyer(s), may cancel this transaction at any time prior to midnight of the third business day after the date of this
transaction. See the following Notice of Cancellation form for an explanation of this right.
ARBITRATION: The contractor and the homeowner hereby mutually agree in advance that in the event either parry has a dispute concemmg this contract, either party may submit such dispute to
a private arbitration service which has been approved by the Secretary of the Executive Office of Consumer Affairs and usi w Regulations and the other party shall be required to submit to
such arbItration as proved In M.G.L. C.142A'�,%-
Contracts ( * Isy—S�� �,f Bayer's rvitiah:
-- " B
r ( � Dais:
NOTICE OF CANCELLATION
NOTICE OF CANCELLATION
-O�you
Date of TransactionIV-10 . you may cancel this transaction, wiMout any penalty or
Date of Trensaution y- may cancel this transaction, without any penalty or
obligation, within three business days from the above date. If you cancel, any property traded in,
obligation, within three business days from the above date. "you cancel, any property traded in,
any payments made by you under the Contract or Sale, and any negotiable instrument executed
any payments made by you under the Contract or Sale, and any negotiable Instrument executed
by you will be returned within 10 days following receipt by the Seller of your cancellation notice,
by you will be returned within 10 days following receipt Dy the Seller of your cancellation notice,
and any security interest arising out of the transaction will be cancelled. t you caecal, you must
and any security Interest arising out of the transaction win be cancelled. If you cancel, you must
make available to the Seller at your residence, in substantially as good condition as when received,
make available to the Seller at you residence, in substantially as good condition as when received,
any goods delivered to you. under this Contract or Sale; a. you may, if you wish, comply with the
any goods delivered to you under this Contract or Sale; or you may, t you wish, comply with the
insmretlons of the Seller regarding the return shipment of the goods at the Sellers expense and
instructions of the Seger regarding the return shipment of the goods at the Sellers expense and
risk. If you do make the goods available to the Seller and the Seller does not pick them up
risk If you do make the goods available to the Seller and the Seller does not pick them up
within 20 days of the date of your Notice of Cancellation, you may retain or dispose of the goods
within 20 days of the date of your Notice of Cancellation, you may retain or dispose of the goods
without any further obligation. If you fall to make the goods avallable to the Seller, or t you agree
without any further obligation. If you fail to make the goads available to the Seller, or t you agree
to return the goods to the Seller and tail to do so, then you remain liable for performance of all
to return the goods to the Seller and fail to do so, then you remain Gable for performance of all
obligations underths Contract To cancel this transaction, mail or deliver a signed and dated copy
obligations under the Contract. To cancel this transaction, mail ordeliver a signed and dated copy
of the cancellation notice or any other written notice, or send a telegram, to A&A Services, 115
of the cancellation notice or any other written notice, or send a telegram, to A&A Services, 115
North Street, Salem, Massachusetts 01970, NOT LATER THAN MIDNIGHT OF
North Street, Salem, Massachusetts 01970, NOT LATER THAN MIDNIGHT OF
(Date)
(Date)
I HEREBY CANCEL THIS TRANSACTION. Consumer's Signature Date
I HEREBY CANCEL THIS TRANSACTION. Consumer's Signature Date
The Commonwealth of Massachusetts
Department of Industrial Accidents
I �•_ :t ' Office of Investigations
R���� f1 600 Washington Street
/ Boston, MA 02111
f ''y www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
M licant Information
Please Print i .p...hl.
Name (Business/Organization/Individual): A A S, r I h �1/1
Address: I IC:; k
City/State/Zip: Df a7 Phone M l 01-711 e7A I _ ori ,q
Aree u an employer? Check the appropriate box:
1.01 I am a employer with (2.
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or
have hired the sub -contractors
listed
partner-
ship and have no employees
on the attached sheet. t
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
3. ❑ I am a homeowner doing
officers have exercised their
all work
right of exemption per MGL
myself [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No. workers'
comp. insurance required ]
Type of project (required):
6: ❑ New construction
7. ❑ Remodeling
S. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11.13 Plumbing repairs or additions
12.❑ Roof repairs
13. [Other D
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy infotion.
rmaI
t affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
I lomcowners who submit this a
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees, B
information. elow is the policy and job site
Insurance Company Name:
Policy # or Self -ins. Lic. #:_�
Expiration Date:_ q f I /'5�� )__ C)'
Job Site Address:_ �� i Prn f-17/Y,3(�I
City/State/Zip: Miq � (0'L f 5
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 tip to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify and h ains an penalties ofperjury that the information provided above is true and correct.
Si nature: -
Date:
Phone #: q1$� rU4 D l -f a li
Oficial use only. Do not write in this area, to be completed by city or town officiaL
City or Town: Permit/License # !
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives, of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other 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
necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to 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 cooperatiori 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
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REP RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Wig`• Y`w�. =/gyp, {�
BUILDING PERMIT NUMBER:., DATE ISSUED:
SIGNATURE:
Building Commissioner/I for of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
aabI Salem sty +
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
A j Da A_ _ /_ gy /e H/9
I V o r a�!
1.3 Zoning Information:
Zoning Distrid Proposed Use
1.4 Properly Dimensions:
Lot Area Fronts ft
1.6 BUILDING SETBACKS ft
Front Yard
Side Yard
Rear Yard
Required Provide Required Provided
R lured Provided
1,7 Water,Supply M.QLCAtI. 54) 1.5. Flood Zone Information:
Public ❑ Private ❑ Zone" ` -Outside Flood Zone ❑
1:8 sewerage Disposal System:
Municipal 0 On Site Disposal Sy.,Wm._
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 1i10LQ11tW1Z1L11UL. r c a IN U
2.1 Owner of Record
Na a (Pr—io Address for Service:
Signature t Telephone.
2.2 . AL4tjonZec1 tk,Cr�}
anr aao ( Sal cry-\ sf ne -e.-F-
Name nt Address for Service:
0-78) r7kil -a)lak
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable ❑
Chrs)h�rDrzu Dj
Licensed Constructi n Supervisor:
U t� License Number
Address
CClgg 7.14l-oHavin
Expiration Date
Signature . _ _-. _ _ Telephone
3.2 Registered Home Improvement Contractor - Not Applicable ❑
Company Name l Q1 LQ oq
Registration Number
(� 50-1 C411A
Address
Expiration Date
Si nature Telephone
SECTION 4 - WORKERS COMPENSATION (KG.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building it.
Signed affidavit Attached Yes .......❑ No ....... 0
SECTION 5 Description of Proposed Work(check all a 8cable
New Construction ❑ Existing Building ❑ -Repair(s) ❑ Alterations(s) Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Description of Proposed Work:
Aeplouo- one -6) ,2niVl.) OIppr-1,/iI+P-' V/
door.
SR.C'TTON 6 - Rv%TIMATR.n C'nNgTRTTCT1nN rncTc
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY .
1. Building
6'5—a6)&' to
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) x tbl
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
bLk;IMfN /a UWINEK AU IHUMIZATIOIN TO BE COMPLETED WHEN.
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
h 0-"/ 1F)Z, as Owner/Authorized Agent of subject property
Hereby authorize 1-Y1S DY -Z, d to act on
behal in all matterelative to otk authorized by this buil ' g permit applicatiopp.
yl1Z/d`l
gignattiie of er- Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, l �V r1 -c, -*D of P % As Owner/Authorized Agent of subject
property J
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Olhrl_S-nehP-r
NO. -OF STORIES
BASEMENT OR SLAB
SIZE OF FLOOR TIlVIBERS 1
SPAN .......
DDAENSIONS OF SILLS
DM ENSIONS OF POSTS
DIN ENSIONS OF GIRDERS
HEIGHT OF FOUNDATION
SIZE OF FOOTING
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
Date
SIZE _
2 70 -
THICKNESS
X
y 4r• r
DISPOSAL OF DEBRIS AFFIDAVIT
A
AV
In accordance with the provisions of: L. c. 40, Sec. 54, a condition of
Building Permit Number is t' the debris resulting from this work shall
be disposed of in a properly licensed lity as defined. by M. G. L. c. 111, Sec.
150a.
The debris will be disposed at: Sale'` 1
'e of PermiWApplicant
Date
Christopher Zorzv
Name of Permit Applicant
A & A Services, Inc.
Firm Name
115 North Street, Salem, MA 01970
Address, City, State, Zip Code
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