HomeMy WebLinkAboutBuilding Permit #859-2016 - 41 Harold Street 2/3/2016iy Rd"du LF
Permit No#: Sq,
Date Issued:
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
NPORTANT: Annlicant must complete all items on this page
LOCATION Fr`te raj %Q w Gti ve/PTTT L
Print
PROPERTY OWNER 57- Si
Print 100 Year Structure yes no
MAP PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Exp.
Date:
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
Others:
❑ Demolition
❑ Other
j n5� /tiho ti
FS
_
odplain D Wetlands
❑ Watershed Dtnct�44
I D UVateg/Sewer
.sr
DESCRIPTION OF WORK TO BE PERFORMED:
g,x>rr?,6 - war// T_rSv /a?io H 4) to Sr Qac c�
Identification - Please Type or Print Clearly
OWNER: Name: k',`r!'S%ry dAaalrMY"t Phone: r>P 9.�'06fA
Address: `'t (
Contractor Name
Address:
ra NO 'S
Pt>-rf t e q HC Phone: ya'-%G3J--
Supervisor's Construction License:
/ o Ga /
Exp.
Date:
Home Improvement License:
Exp.
Date:
ARCHITECT/ENGINEER
Address:
Phone: ,
Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ a FEE: $
Check No.: Receipt No.: 2gl-n
NOTE: Persons contracting with unregistered contractors do not have accessto the guaranty fund
1
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
s
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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
Reviewed On Signature
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
ti.
:,onservation Decision:
Comments
Com
Water & Sewer Connection/Signature &Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
G
_Stree,�
)epartm� esi 4 r�
gnture/dated _ _ ��
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: lies No
MGL Chapter 166 Section 21A—F and G min.$10041000 fine
NOTES and DATA -- (For department use
❑ Notified for pickup Call Ema
I Date Time Contact Name 3
Doc.Building Pennit Revised 2014
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
16 Copy of Contract
4 Floor Plan Or Proposed Interior Work
4. Engineering Affidavits for Engineered products
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/Cross Section/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 .
OTE: 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
2012 IECC Energy code
Engineering Affidavits for Engineered products
TOTE: 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: Building Permit Revised 2014
'Olt psr-04
v
21�
Location
No. Date2
1z, V -al C\----kAAa-4AA
TOWN OF NORTH ANDOVER
"I -I �1
Check #
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
Building Inspector
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Federal iD d 060401628
RISE Engineering
No 120979
10%c
A division of Thielach Engineering
RISE
ENGINEERING 60 shawmot, Canton, MA 02021 CONTRACT
339.501.6197 339 -x? -6345
,
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PROGRAM
TWBW RW
CMA-HES AWDO COKITRACT TIMC STO NTBED FORWOWAS
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CUSTOM ofV1
N AWNS DME cums WORK01WEt
Kiersten Gaudette o (978)989-0682 09232015 422240
00003
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SEW= STRAW IUUI mento STREET
41 Harold Street Sl # th 41 Harold Street Sl
a CIM STAW.MP 06100 CRr STATEZ[P
North Andover, MA 01845 .IL -11—J.1 North Andover, MA 01845
DESCRIPTION
AIR SEALdNG: Pmvide labor and materials to install Q-lon weatherstripping and a doomweep to (2) door(s) to restrict air leakage.
$150.00
WALLS: Furnish and install blown in Class I Cellulose to (1440) square feet of shingle andlor clapboard exterior walls. The butt of
the upper course of your wood siding is art to drill holes into the wall sheathing behind. The holes are then plugged and the wood
siding is masfslled using stainless steel finish nails. Touch-up painting, if needed, will be the customers responsibility. Invoicing will
occur upon completion of msWh m Subsequent to your payment, as an added service, RISE Engmemng will return when weather
permits to check for any voids with an infrared scanner Any major voids that may be found will be filled at no additional cost.
$2,664.00
RISE Engineeing will apply all applicable, eligible incentives to this contras. You will only be billed the Nct amount Cmrcudy,
for eligible measures, Columbia Gas offers 75% incentive, not to exceed $2,000 per calendar year, and an incentive of 100% for the
Air Sealing measures up to the Srst$680 and an additional $340 if savings are juWfied by the auditor.
For the safety and health of your home's indoor air quality, we will be conducting a blower door diagnostic of the available air flow in
your home both before the work is began, and after the weeiberizadon work is complete. We will also conduct a full assessment of
the combustion safety ofyour heating system and water heater. This has a value of$90 and is at no cast to you. Total allowable
weetherization incentive is $3,110.
$90.00
Total:
$2,804A0
Program Incentive:
$2,080.00
Customer Total:
$81400
WE AGM NBVW TO RWaSN SERVMM -COMPLETE w ACCORDANCE vara ABOVE SPEC(FICAYMM FOR ntE SnM of
""Eight Hundred Fourteen & 001100 Dollars
$814.00
UPONFMUU.MPBGTeD MMAPNMAL6Y=Et2CO8T=MAWMSTOMWABOUt UMWFULLMEAEBTOFt%VMLBEC"A 6 (OMILLYONAM
Ue�AiDaNANCEAFT030DAY8SEEREVERSEFORWORTAM'ONIATWNON SUAR11N7F8B,l nSOF N,8CNE�tgaq,ANDOONIRACTOaREDIBTRATiON.
Do NOT SON nils CGUMCT F 71WE ME ANY BLANK SP
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AUTWW=S1QWTQW.MW EapioeMaB CUSTOM ACCEPTANCE
6�NOTE
TIES COIrtP = VAYSE WrINDAAIM UV US 8= NOT E MWM WMM DATE OFACCEPTANCE `�
ACCEPTANCEOFCOMPACT-TNEMMEPRICES:S BCWAMMAMDCOfIWr OMARE
30 AM110Rt�T000
DAVS' ASSPECO•TPD.PA WWWSLSEWDEASOUna�AME
THElYORK
OWNER AUTHORIZATION FORM
1 Nick Brings
(Owners Name)
owner of the property located at
39 Harold Street, North Andover, MA 01845
(Property Address)
391Harold Street, North Andover, MA 01845
hereby authorize ,
(Subcontractor)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perforin work on my property.
Owner's SignatW
q� l
• l5
The Cottartaonraealth ofiWassaehtasetts
Department Of ndustrial ACC denIs
I Congress stree4 suite 100
Boston, YL4- 02114-2017
www-MaS&gov/daa
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
To BE HLEID WITH THE P ERNGTTING A T3'HORIITY :
Name (Business/Orpnrrationllndividual):—L
Address:
city/state/zip--_
Phone #:
Are you ne employer? Ox-ck tilt appmprbec troy:
1 _ tY 18m 8 rmplDyc with /. employees (fil) nodlor pari -time)_ -
2 f 3 I am a sole proprietor or parUxrsbip rad have no employees working for me in
any arty- [No workers' comp_ innrmace -quire&]
3-01 am a bomeowncr doing all work myself [No woskers' comp- instssance rcquL-cd ] t
4-C]I am a homeowner and will be hiring contractors to conduct all work on my property- I will
cnstrrc that all contractors atber have workers' compensation insurance or are soli
prvlxiclots frith aro employees -
5.Q i am a general contractor and I have bkcd tl=sub-coorrzctors listed on thcattached shect-
71= sub -contractors have employees and haveworkem* comp- insraaoccr
6.O We azo a corporation and its officers have cxcmised their right of oceraption per MGL c-
.
. 152, §1 (4), nod we have no employees. [No workas' comp- insia-an=e tsquirtd.]
Type of project (required)-
7- New construction
8- E) Remodeling
9_ El Demolition
10 Fi Building addition
11-0 Electrical repairs or additions
12- Plumbing repairs or additions
13.FlRoof repairs
1 4.0IOther
-Any applicant tbai cbecks box #i mtw ALSO ftlI ow the section below showing their workers- cnmpensatioa policy information -
t Homeowners who submit this affidavit indicating they rue doing all work nod then bim outside contractors mast submit a a. affidavit indicating such_
tCoonactocs that check this box must aruxbod so additional sheer showing the name of the sill-cootraernrs and sate wbetbcr or Dot those eatid- have
®playccs If the sub contractors have cmployces, they must provide their workers' comp. policy numbrr-
I ami are employer that is providing warkers' compensafaon insurancefor my employeez Bdow is thepolicy aaedjob site
information_ /
insurance Company Name: .f 1 G `-C i << ✓ �� %�
Policy # or Self -ins- Lic- #: 7v (,JG _7%�=, J Expiration Date: �
Job Site Address: � l 0/1q 1-0 (f!� � i City/StaterZ-ip:
Attach 2 copy of the workers' compensation policy declaration page (showing tine policy number led espirnt on date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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
lay against the violator- A copy of this statement may he forwarded to the Office of Investigations ofthe DIA for inatrance
overage verification.
r do hereby certify under die prams and penalties opperjaary that the information provided above is true and corm
signature: 11i t c'6 % - Date:
'hone -Y --7 O L'
Oficial use only. deo not write in dds area, to be cOmPleted try city or town OJ7eaLt
City or Townt
Permait/Ucense #
Issuing Authority (circle one):
1_ Board of )health 2. Building DVartment 3. Cinyfrown Clerk 4. ]1qlectdcal lnspet-tor 5. Plumbing InspeCtor
6- Other
Contact Persona_
Phone
1/412016 Preview: Certificates of Insurance
-1 OO
ACQRV ICERTIFICATE OF LIABILITY INSURANCE
DATE R.ed1DDNYYY)
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0110412016
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) must 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 bolder in lieu of such endorsement(s).
PRODUCER
CONIACr
NAME'
Automatic Data Processing Insurance Agency, Inc.
PHONEAX
rare. No. Enc wtc. No):
ADDRESS'.
1 Adp Boulevard
INSURER(S)AFFORDING COVERAGE NAIC9
Roseland, NJ 07068
R)SURER A: NorGUARD insurance Company 3 31470
CLI:LACiREGAit1-11.111 APFLIEtil+l'
1'i:LIC'. IRE:)
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INSURED
INSURER B:
POLAR BEAR INSULATION CO INC
PO BOX 958
INSURER C:
Andover, MA 0181 D
INSURER D:
INSURER E:
INSURER F :
li::Ull'i Ir;JI_I::' zv- I,3* _'n: 5
COVERAGES CERTIFICATE NUMBER: 429703 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES 0= INSURANCE LISTED BELO7i HAVE BEEN ISSUED TO THE INSURED NAMED AZOVE FOR THE POLICY PERIOD
1NDiCATED. NOTL?ITHSTANDING ANY REOU;REL:ENT. TEPM OR CONDITION OF ANY CONTRACT OR OTHER DOCUIIIENT 4r:TH RESPECT TO :7HiCH THIS
CEP.TIF;CATE 14AY BE ISSUED OR NAY PERTA:11. THE iNSUP.ANCE AFFORDED BY THE POLICIES DESCRIBED HERE:N iS SUBJECT TO ALL THE TERLIS.
EXCLUSIONS AND CONDI7;OAIS OF SUCH POLICIES LILHTS SHOW: N VAY HAVE BEEN REDUCED BY PAID CLAI 'S
WSTt
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TYPE OF INSURANCE
INSO
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POLICY NUMBER
P LI 'Y t
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P LICY P LGSRS
YYYYi
Cranston, RI 02910
COMMERCIAL GENERAL LIABILITY
CLAILIS LIAVE u L.t:Ll.
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AUTOM,OSILE
LIABILITY
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ANDEMPLOYERS'LIABIIIrYSI:JLIE
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+FFICEI:LI`L16F1:E;:LLL�G' �r)IA
(ftantlalory in NH)
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E.LLL'E!•SE I:'- L'r.11l 1,000,000
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DESCRIPTON OF OPERATIONS? LOCATIONS I VEHICLES (ACORD 101. Additional ROmmks Schedlde. m J be attached it nim space is req,rired)
ULKIWICAIE HULUER r6tdrPl 1 AT1nrd
A'—' 19t1t1-ZU14 AGURU CORPORATION_ All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
Theilsch Engineering, Inc.
ACCORDANCE WITH THE POLICY PROVISIONS.
195 Frances Ave
Cranston, RI 02910
AUTHORIZED REPRESENTATIVE
I
_ -
A'—' 19t1t1-ZU14 AGURU CORPORATION_ All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
POLASEA-01 JONEiLL
A�oizo CERTIFICATE OF LIABILITY INSURANCE DATE{MNUDD/YYYY)
1/x/2016
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(les) must 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
NAME:
Durso & Jankowski Insurance Agency PHONE — -- PAX —
11 Saunders Street ac, N, 978 688-7000 _ —{ac No : 978 688-7001
North Andover, MA 01845 EMAIL
INSURED
Polar Bear Insulation Co. Inc.
Peter Leblanc & Steven Leblanc
P O Box 958
Andover, MA 01810
INSURER(S) AFFORDING COVERAGE
_ INSURERA:Nautilus Insurance Co. _
INSURER B: Safety Insurance Company _
INSURER C
INSURER 0:
-INSURER-E:
INSURER F:
COVERAGES CFRTIFICATF NIIMRFR- 0G111101f%m Nil IMRFR-
NAIC#
17370
33618
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 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR I TYPE OF INSURANCE i INSD WVD I POLICY NUMBER
POLICY EFF^ (MMM; i LIMITS
I MM/DD MMroD
A I X I COMMERCIAL GENERAL LIABILITY
I INN538691
� CH OCCURRENCE $1,000,000
—,
CLAIMS MADE '! X i OCCUR i I
i 03/24/2015 i O�/24/2{)j 6 DAMAGE TO RENTED - -- --- --
PREMISES (Ea occurrence) $ _ . 50,000
i.;
MED EXP (Any one person) ; $ 5,000
'
PERSONAL & ADV INJURY $ 1,000,000
GGEEN'L AGGREGATE LIMIT APPLIES PER: ' I
I GENERAL AGGREGATE i $ 2,000,000
A I POLICY I JEC (- -LOC I
_ -_ (((
i
-- -- I --
I ! PRODUCTS - COMP/OP AGG ; $ 1,000,000
--"- --- - ------ ' "---------
{
OTHER: I
I$
B
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT i $ Eaa—dent_1,000,000
j_ _ _ _
i ANY AUTO i i 12100926
ALLOWNED X' SCHEDULED
1 01/0412016: 01/04/2017 ! BODILY INJURY (Per person) i $
--
BODILY INJURY (Per accident) ! $
AUTOS _ AUTOS
-XC" HIRED AUTOS '. X NON-0WNED i
_ AUTOS
I I PROPERTY DAMAGE j $ '
+. (Peraccident
UMBRELLA LIAB ! X ; OCCUR
EACH OCCURRENCE $ 11000,000
A CESS LIA6 _f � CLAIMS�VIADE i I AN019284
, —Ii
!03/24/2015 03/24/2016 AGGRE-G—ATE--'-- - i $ -
—
' DED ! RETENTION $ I I
I I $
WORKERS COMPENSATION
0TH- +
ER-_
AND EMPLOYERS' LIABILITY
YIN'
MANY PROPRIETORIPARTNERIEXECUTIVE
_I",STATUTE
!
Is
OFFICER/MEMBER EXCLUDED? I N /A
CI
(Mandatory in NH) I
i E.L.E.EACH ACCIDENT
i I -
i E.L DISEASE - EA EMPLOYEE; $
�-
If yes, describe under
DESCRIPTION OF OPERATIONS belowE.L
DISEASE - POLICY LIMIT i $
�
I
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Insulation Work - Mineral
Insulation Work - Mineral; Additional insured for general liability per blanket additional insured endorsement with respects to work performed on their behalf
by the above insured is Thielsch Engineering
CER I11 -ICA 1 E MULUER r`ANCGI I ATInN
rl AQOO nn7 A Afle%nr% r%r%X nf%n A rrnwr All -...L.M-......�.,�,r
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Thielsch Engineering Columbia Gas
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
195 Francis Ave
ACCORDANCE WITH THE POLICY PROVISIONS.
Cranston, RI 02910
AUTHORIZED REPRESENTATIVE
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- 02116
Boston,assachns_
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j�0II1 _ =_ Reg MOB -A# 252M
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