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Home My WebLink AboutBuilding Permit #57 - 340 BRADFORD STREET 7/23/2008 BUILDING PERMIT oI pORTF/ qti TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received °0, 7tO.fi`�5 ' ✓23 r t) � 9SSACHU`��4 Date Issued: IMPORTANT: Applicant must complete all items on this page 7-7 WL r 12 IS RR0P -OW §{ �, • tea'-., _- Za+,. £t�x,11[ � a, :iy T�aaw -,a.- 4 -4 - 1V1AkIO � P�ARCEL : ONNG DISTRIC � rstrncDrst>i res ag ; . � '. - 1VIacliinehopil"ae Yes :no# m TYPE OF IMPROVEMENT PROPOSED USE Reside Non- Residential New Building CQne family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other n Septra IP�Vejl setaoFWD .�tct _ DESCRIPTION OF WORK TO BE PREFORMED:4 ry Gl� n d P ��v Ic Identification Please Type or Print Clearly) OWNER: Name:��,S lt4".74 1 G Phone: �� G(9o?1?007 CJ Address: rc -for S � CCCI f FZPCi` fR `ieac ' '17£1 ;1's' t 4 r A-c�" ess - ,.. 'a .i "43'"1�!` � '.. .a. «. �' " ,.., r-..�.u' 's,Y=.V s sa k Su, ervi a'sC troc n LrcenXpu. 3 Home r r�u�emen Lat;eTs � cp Die . �P _ ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT:$1200 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Proj1ect Cost: $ �/� LS FEE: $ d �i Check No.: Receipt No.: a 3 S I NOTE Persons contracting with unregistered contractors do not have access to the guaranty u Sk. - �� - � • 1gn�at�re ofent/Owner.0 ;. - � '� � �•Slg�ature of�contraetor - �, Location 3/`) No. ®ate NORTH TOWN OF NORTH HANDOVER " Certificate of Occupancy �'�s'•^�;<� Building/Frame Permit Fee .Ks Foundation Permit Fee $ Other Permit Fee $ s— TOTAL 3 Check # 2 i 351 Building Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales 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 Siqnature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments i Conservation Decision: Comments I I Water & Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRS DE�'A£RTMEiT Temp.D'arrastern mite yep Lora#ed°at 1, t'ain Street ire T).e rtmeh s t ye/date. _ to .f. QaU1111ENTS 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 4 PP 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 2008 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 o 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 o 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) o 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 o 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 Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 Board of Budding Regulations and Standards HOME IMPROVEMENT CONTRACTOR ' j Registration: 141507 " --,P-!t1on : 4/26/2010 Tr# 265184 j Ty Ltd Liability Corpor SUN-RAY BUILDERS JASON TARDIFF j 15 NOTRE DAME AVE` ALLEN'STOWN,NH 03275 , e Boar u� m Construction g .egu afio�fs,a Supervisor License." ar �, License; CS 86380 #: EXBratton { 11/3/2009 Tr#`10573 esr�dtion ppr" -t:' � _97 i Y JASONq TARDfFF � r 15 t NOTRE D tl AME ALLENSTOWN, NH Commissioner NORT#q Town of , tAndover 0. No. p �- �. o LANE dover, Mass., Ap H '•�� ' oY Q �. COCHICEWICK\V %ADRATED I'P� �5 `s BOARD OF HEALTH PERM .IT T D Food/Kitchen Septic System BUILDING INSPECTOR Ad THIS CERTIFIES THAT..........J..10 .... ......... .n.f./� .......................................................................... • Foundation ont has permission to erect........................................ buildings on ....... d......... �';,.�� ..Jam' Rough �0� �r �! Chimney to be occupied as........................ ...�... ��f.........................fl. ..1.............. ....................................................... provided that the person accepting t is permit shall ire everyrespect 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 Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR. 3000P UNLESS CONSTRU ST S 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 z. Street No. SEE REVERSE SIDE j Smoke Det The Commonwealth of Massachusetts N; Department of Industrial Accidents Office of Investigations 11- Il4 600 Washington Street i ` Boston, MA 02111 t i~ www.mass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information (� Please Print Legibly Name (Business/Organization/Individual): S�G.'? 4 Address: 13 /Z//6 c, k s--e 71- f/SArCity/State/Zip: 6 x 03/4 k Phone #: 66-,5 3QG 6 ,913— Are e you an employer?Check the appropriate box: Type of project(required): 1.12ZI,ani a employer with c 4. ❑ 1 am a general contractor and 1 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 1 7. ❑ Remodeling 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.] officers have exercised their 10.E] Electrical repairs or additions 3.F_1 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.E] Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 131-1 Other *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are dviiig all work and ihen hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: V S Policy#or Self-ins. Lie.#: t4-)C .�"- 3/S— (A/O�621V- 6 F7 Expiration Date: 70 Job Site Address: 3 el- 0 13r, J��4 $T City/State/Zip: /L�, c� r 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. /do hereby certify under the pains andpenalties of perjury that the information provided above is true and correct Si nature: Date: 7-,;;?S, G <' Phone#: 0-j 3 OG 6 V �S 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. 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-contractor(s)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. Aliso 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 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. # 617-7274900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 ww,mass.gov/dia MAY-21-2008 14:15 SURGE 603 624 7007 P.001 AMR-A. CERTIFICATE OF LIABILITY INSURANCE OS/2 IIMDD/YYY1) OS/2 PRODUCER 1-617-723-7775 THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION Bays Companies of Now England ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 133 Federal Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 3rd Floor Boston, MA 02110 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER&Liberty Mutual Sun-Ray Builders LLP INSURERS: PO Box 3217 INSURER C: Manchester, NE 03105 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 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR WL pOLICYNUMBER POLIICYEFFECTIVE POLiC EXPIRATIONTYPE OF INSURANCE 1ATEI IMMWMn LIMITS GENERALLIAOILITY EACHOCCURRENCE S DAMAGE - COMMERCIALGENERAL LIABILITY P E SE IE occ� uLenul _ S CWMSMADE F7 OCCUR MED EXP(Ariy oneperson) S _ - PERSONAL BADVINJURY S GENERALAGGREGATE $ GEN'LAGGREGATELIM17APPLIES PER: PRODUCTS-COMPIOPAGG S POLICY O LOC AUTOMOSILB LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea acoldent) $ ALL OW NED AUTOS BODILY I NJURY SCHEDULEDAUTOS (Perpeman) $ HIRED AUTOS _ BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTYDAMAGE $ (PeraccMenl) GARAGE LIABILITY AUTO ONLY-EAACCIDENT $ ANY AUTO OTHER THAN EAACC $ AUTOONLY: AGO $ EXCESSIUMBRELLA LIABILITY EACHOCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ S U1 WORKERS COMPENSATION AND 9PC5-31S-360214-097 10/01/07 10/01/08 RWe sTATu- OTHEEL - EMPLOYERS'UABILITY ANY PROPRIETORFPARTNERIEXECUTNE E.L.EACH ACCIDENT S1,000,000 OFFICER/MEMBEREXCLUDED9 X E.L.DISEASE-EA EMPLOYEE 51,000,000 Ifyes.deEcrlbeunder SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS This policy covers those employees leased by Sun Ray Builders, LLP through Surge Resources, Inc., Manchester, NE 03109 CERTIFICATE HOLDER CANCELLATION*3.0 Days for Non Payment of Premium SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BECANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL *30 DAYS wMrTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER.ITS AGENTS OR REPRESENTATIVES. _ AUTHORIZED REPRESENTATIVE ACORD 26(2001108)mvaughfi2 ®ACORD CORPORATION 1988 8831905 CertHlcate Delivery by CertlOcatesNow-www.ConfirmNet.com-877.669.8600 6/16/2008 3:08 PM FROM: Watson Insurance Age Watson Insurance TO: +1 (603) 622.-0658 PAGE: D02 OF 003 C'ORD',, CERTIFICATE OF LIABILITY INSURANCE 6/12/2o 8 PRODUCER (603)668-4800 FAX: (603)668-2400 THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION Watson Insurance Agency, NLY AND •CONFERS NO RIGHTS UPON THE CERTIFICATE 4 cY r Inc.. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 50 South Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Manchester NH 03102 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:Peerless Insurance Co. 24198 Sun-Ray Builders, LLP INSURERS PO BOX 3217 INSURER C. INSURER D: Manchester NH 03105 INSURER E: 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. kTF-LIMITSS OWNMAYHAVEBE q REDUCED BY PAID CLAIMS. INSR ADD'L POLICY EFFECTIVE POLICY.EXPIRATION I TYPE OF INSURANCE POLICY NUMBER DATE MIDDAY DATE MMIDDNY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 100 000 PREMISES Ea occurrence $ A CLAIMS MADE FX�OCCUR CBP8235158 1/5/2008 1/5/20.09 MED EXP(Anyme verson) $ 5,000 . _ PERSO AL d ADV INURY 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 X POLICY PRO- LOC . .. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANYAUTO (EeacddeM) ALL OWNED AUTOS BODILY INJURY $ - SCHEDULED AUTOS (Per person) HIRED AUTOS „ BODILY INJURY $ NON-OVNED AUTO S - - (Per acddem) PROPERTY DAMAGE $ (Per amdent) GARAGE LIABILITY - - AUTO ONLY-EA ACCIDENT $ AtdY AU TO OTHERTHAN EA ACC $ AUTO ONLY: C $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE OCCUR F7 CLAIMS MADE - - GTE DEDUCTIBLE $ RE7ENTI N WORKERS COMPENSATION AND Y TAT - OTH- EMPLOYERS'LIABILITY ER ANY PROPRIETORIPARTNERIEXECUTIVE - E.L EACH ACCIDENT OFFICER/MEMBER EXCLUDED? El DISEASE- EMPLOYE SPECIAL Ryes,describe under PROVIIONS below- - - .. -_...-_d.='.:. E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONSILOCAT16NSIVEHICLESIEXCLUSION3 ADDED 13ENDORSEMENT%SPECIAL PROVISIONt Covering the operations of the insured. j CERTIFICATE HOLDER - CANCELLAf1013,,., T �'Sri=n. SHOULD ANY OF-.FHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE ;THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS'WR'I+ 15 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 So 6HX! LIMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AG6ryTS:OR'REPRESENTATIVES. AUTHORIZED REPRESENTATIVE rya - Jim WatsonMFS ACORD 25(2001108) m ACORD CORPORATION 1988 INR095 inln4�nca Dana 1 nf9 PAGE NO. OF PAGES N11 0 11 � Sun-Ray guilders PHONE DATE P.O. Box 3217 Manchester, NH 03105-3217 ` Tel. (603) 300-6915 Fax (603) 622-0658 J� EMAIL ADDRESS SUBMITTED TO-. �fi _ /SIN S— ! - r �+ JOB NAME STREET U __.r.✓._ ._.,_. _. JOB LOCATION CITY,STATE ANDZIP.10 __._. ___.___�� jr�! _,_____.___ JOBPHONE Lei 9 . ---- -------- .r rj�Ulf Ll WE PROPOSE HEREBY TO FURNISH MATERIAL AND LABOR—COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS,FOR THE SUM OF: DOLLARS PAYMENT TO BE MADE AS FOLLOWS: _ All material is guaranteed to betas specified.All work to be completed in a workmanlike manner according to-standard practices.Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the AUTHORIZEQ/a(__� estimate.All agreements contingent upon strikes,accidents or delays beyond our control.Owner to SIGNATURE carry fire,tornado and other necessary insurance.Our workers are fully covered by Workmen's Compensation Insurance. ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPECIFICATIONS AND CONDITIONS ARE SATISFACTORY AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO THE WORK AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE. SIGNATURE i"^.�'t! f-�r' ./1 a".Na"* DATE eE"+.^ . 7Dl0 H SIGNATURE DATE