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Date. . . ?I�Jl2or
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
,SSACHUSE�
This certifies that
......... ........ . .
has permission to perform
plumbing in, the buildings of -3-1�1 .................
at . 5 ..� . d /) o A -2,b
.................... North Andover, Mass.
Fee. ... Lic. No...(K . .................. ............
PLUMBING INSPECTOR
Check 4 J
6" 76
I
.A
MASSACHUSETTS UNIFORM
(Print or Type)
Building Location_ a
9 -7 S 7-,Q
New ❑
TION FOR PERMIT TO DO PLUMBING
Permit #
Owner's Name—.,.. Sc f r3&G
Type of Occupancy Residential
Renovation ❑ Replacement N Plans Submitted: Yes ❑ No ❑
FIXTURES
Installing Company Name Heritage Htg. &Pig. Co. Inc.
Address35 plea Gant Street
Stonehamy Ma 02180
Business Telephone • 781 —43 8-7776
Name of Licensed Plumber Gordon Switzer
Check one:
IX Corporation
❑ Partnership
F1 Firm/Co.
Certificate
714
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
-Yes ® . No ❑ .
If you have checked j _,.please indicate the type coverage -by checking the appropriate box.
A liability Insurance policy IN Other type of Indemnity. ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement.
Check one:
Owner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit Issued for this application will be in compliance with all .
pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
Signature o Licensed umber
Title e
City/Town
Type of License: Master [X Journeyman ❑
APPRdVE O License Number 8 3 2 2
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Installing Company Name Heritage Htg. &Pig. Co. Inc.
Address35 plea Gant Street
Stonehamy Ma 02180
Business Telephone • 781 —43 8-7776
Name of Licensed Plumber Gordon Switzer
Check one:
IX Corporation
❑ Partnership
F1 Firm/Co.
Certificate
714
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
-Yes ® . No ❑ .
If you have checked j _,.please indicate the type coverage -by checking the appropriate box.
A liability Insurance policy IN Other type of Indemnity. ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement.
Check one:
Owner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit Issued for this application will be in compliance with all .
pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
Signature o Licensed umber
Title e
City/Town
Type of License: Master [X Journeyman ❑
APPRdVE O License Number 8 3 2 2
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Date............. ......
40RTH
TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
C.�4 t
This certifies that .......... .........
.......... .. .........
...........
.
............ Ity...
has permission to perform ............................. Aw.o(......... ....
wiring in the bpilding of
at.
................. . North Andover, Mass.
!�4*
Fee.A�O().. Lic.No
.......................................................
ELECTRICAL INSPECTOR
Check #
5465
I
_ _ Lomnwnwen (L1c of rr�a9socl[rc3e1�
oLl¢17Q rinie r]L O�Jile �¢l4l CZE
BOARD OF FIRE PREVENTION REGUI i
APPLICATION FOR PERMIT T
1\11 work to be pertormcd in accordance with ih
(PL E,ISL• PRItVT IN INK OR TYPE , ILL ItVr0Rt11.17'
City orTown own of:
By this application the undersigned Lives notice of his or h
Location (Street & Number)
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building penuit?
Purpose of Building
Existing Service
New Service
Anips / Volts
Anyts / Volts
Number of Feeders and Ampacity
ocation and Nature oC Proposed EI trical Work:
Official tjsc Only
Occupancy and Fee Checked cl��
TIONS [Rev. 11/991 ----
(Icavc blank)
E
FORM ELECTRICAL WORK
cts Electrical Code (MEQ 527 CNIR 1200
Date: 10 To the Inspector of
rCortrt the electric i %v described below.
U) P.
Yes ❑ i to
Telephone No.
(Check Appropriate Box)
Utility Authorizativn No.
Overhead ❑ Undgrd ❑
Overhead Undgrd ❑
C&
No. of t\feters
No. of.Meters.
No_ of Recessed Fixtures
- -
r`Io_ of Ccil_-Susp_ (Paddle) Fans
111-r— nun cu OL' UrC his ector o! Wires_
No. of Total
Transformers KVA
No. of Lighting Outlets
No_ of Plot "Tubs
Generators Ii\'A
o. o mergence ig ntiirg
No. of Lighting Fixtures
Srvimmin. Pool Above ❑ In- ❑
rnd.
o�13111ell
Batte UnitsNo.
of Receptacle Outlets.
FIRE ALARIVIS
No_ of Zones
No. or Switches
i urners
No. of Detection and
I ii(iatinQ Devices
,No. of Ranges
No. of Air Cond. rotal
Tons
No. of Alerting Devices
\o. of Waste Disposers
Hcat Yump r`lumber 'i'ons K\V_
—
No. of Self -Contained
Totals: —
Detection/Alerting Devices
N'o_ of Dishwashers
Space/Area Heating KW
Local ❑ Muaticipal
El Connection Other
No_ of Dryers
Ileating� Appliances K\y
Security Svstenis:
NO. of Water —
No. of t\o. of
No. of Devices or E uivolent
Heaters '�„
Sins Ballasts
Data 1\'i rino.
--:No.
No. of Devices or Equivalent
Hydromassage Bathtubs
INN. of Motors Total HP
I elecommunications \Viriitg:
No. of Devices or E uivalent
OTHER:
,--- — ..1.111 y urs,rca, or as required bt. the Inspector of {Vires_
INSUFZ4.NCE CO\-EI?AGE: Unless waived by the owner, no permit for the performance of electrical xvork may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such cov�BONZEI
n force, and has exhibited proof of same to the permit issuing ofijce.
CHECK ONE: I\'S Rf\NCE OTHER ❑ (Specify:) k �- %C9 ns, /o? —0 Is
.�.C. ,Ty S" S -s n u81 tc So
/ c� (E.�p ration Datc)
Estimated aloe of Electrical 1Vorl:i/ �Q � (When required by municipal policy-)
`•Fork to Start f Inspections to be requested in accordance with MEC Rule 10, and upon completion.
/ Ce•rtifj•, it /I the 115itr�il1 pe•naltie•s of per !rr)•, thaf the urfo nation Ott this application is trite aril completc_
F1101 NAI1IU: J Gr ��f �Q 0174't6 A � � A LIC_ NO.:
Licensee_
(Ifopplicoble. eats
Address:
OWNER'S 1N
required by law.
Owner/Agent
Signature
yfl;�
fir/ wsr `7 r �^ JIb11 llU1 e rJ (� -G/ LIC. NO.:
" cry nlpt ' in the hccrrse ntuuher line.) / Bus. Tel. No,:
�C / Alt. Tel. No.:
.ANCE \VAINER: 1 am aware that the Licensee does not /rrn'e the liability insurance cove ra2c normally
B\my signature below, l hereb}' waivc this requirement. I ant the (check one) ❑ o« ncr ❑ o\� ucr s aLent.
Telephone No. Pi Rt1IIT FLL: S
INSPECTION RECORD
Date Notes — Remarks Inspect
i--
-41 44
Date ............ �k ......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies thatI C A
that....................... / ................................................................................................
has permission to perform ....... 4 ....... e .... CAO 94P4 lb.. (1-6 ........
,--. / ... .: ........... .... .....
wiring in the building of e
.... rl ..............................................................................
at ........ 4-J. . rth Andover, Mass.
*.* .* .............
Fee—=!ff: . .................. Lic.
ELECTRICAL INSPECTOR
Check#
2"13
la\- Commonwealth of Massachusetts Official
( Use Only
Department of Fire Services Permit No. ROOM� `T
` p Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank
5
W
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC) 527 qMR 12.00
(PLEASE PRINTTNMK OR TYPE ALL INFORMATION) Date: 11 N I(T
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice ofAp his or her intention t�(e�rform the electrical work described below.
Locatinn (Street & Numbed In 1A R N yellow ;1� 1.1
Owner or Tenant
Owner's Address
r;&I,<
Is this permit in conjunction with a building permit? Yes IA
Purpose of Building �4wid , RM
Overhead ❑
- Existing Service
New Service
Amps / Volts
Amps / Volts
Number of Feeders and Ampacity
Telephone N
iWrik hki([- 115 S
No ❑ (Check Appropriate Box)
Utility Authorization No.
Overhead ❑
Undgrd ❑ No. of Meters
Undgrd ❑ No. of Meters
l�
Location and Nature of Proposed Electrical Work: � ��� � Ncen N CAA
Completion ofthe following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires '�
No. of Cell: Susp. (Paddle) Fans
Tr s Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In- ❑
rnd. grnd.
o. o mergency Lighting
BatterV Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ran es
g
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
p
Heat Pump
Totals: I
Number
Tons
I
KW ..........
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
S ace/Area Heating KW
p g
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Sectio. o of Devic : or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
Icertify, under thepains andpenalties ofperjury, that the information on this application is true and complete.
FIRM NAME: _ O LIC. NO.:
Licensee: M,GLktJ M? I a8btp Rade Signature_ az� LIC. NO.:
(If applicable, enter "exempt" in the license number line.)L Bus. Tel. No.:
Address: S(� �(�l b, Wo gn(f k Ab Alt. Tel. No.: n —- 41�
*Per M.G.L c. 147, s.57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMITFEE. $ ZSiv)
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the F
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑
❑ Permit Extension Act—Permit/Date Closed:
Trench Inspection
Pass M
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass 0
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass 0
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSPE ON:
Pass M k
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com
f
The Commonwealth of Massachusetts
Department ofIndustrialAccidents
1 Congress Street, Suite 100
Boston, MA. 02114-2017
www mass.gov/dia
Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY-
Name
Addre _
City/State/Zip• rJ1,�r.� ��'�� M Phone #:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with employees (frill and/or part time).*
2. ❑ I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.Q I am a homeowner doing all work myself [No workers' comp. insurance required.] t
4.F]I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5. ❑I am a general contracto 'and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance
6 We are a corporation and its, officers have exercised their right of exemption per MGL G.
152 § 1(4) and we Have no employees. [No workers' comp. insurance required.]
1%
W
Type of project ()Vequired)'
7. NdVd6nstruction
8. Remodeling
9. Demolition
10 [] Building addition
11.[] Electrical repaixs or additions
IZ. [}Plumbing repairs or additions
11E] Roof repairs
14.[] Other
*Arty applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information: •
i Homeowners who submit• this afffda1.bit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this liox must attached'an additional sheet showing the name of the sub -contractors and slate whether or not (hose entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
X am an employer that is providing workers compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: "
Policy # or Self -ins. Lic. #: 0 AW L 6 �_tW- . Expiration Date, i . /
Job Site Address:
J (,� 1�„� t� D ! City/State/Zip:�� 9 �l'"� N
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date .
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a Pirie 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. 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 and penalties of perjury that t g information provided above is true and correct.
X
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): i
1. Board of health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Phone #:
Contact
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their eailployees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of W6,
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 6f an individual, partnership, association or other legal entity, employing emplbyees:. 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 b6 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 theperformance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Pleasb 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 ceriifteate(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
IndustrialAccidents. 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
thai 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 burst leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 wwwmass.gov/dia
Date �!
(,,1 ! .1 1 .
Off. . tom'
t
ell -
TOWN OF NO TH ANDOVER •
PERMIT FOR WIRING
This certifies that. DO W12.. ...........
has permission to perform ..
wiring in the buildin of ... n'p '�, ..........................
at .... ..G a?�'� orth Andover, Mass.
v -�
Fee :��`��.—'.—. Lic. No. I.3 .W.. ............. ... // . .
-� ELECTRICAL INSPE&T
Check #
10901
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance-with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice o�installation of wiring shall be uniform throughout the Commonweaidt, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appoir d p rsuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or-corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall-be limited as to the time ofongoing construction activity, and may be.deemed-by the-Inspector-of Wires abandoned.and-invalid_iflme—_.. _
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
puipose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008andextending"through August 15, 2012.
le 8 — Permit/Date Closed: ��! ` c *** Dote: Reapply for new pe
0 Permit Extension Act — Permit/Date Closed:
0
V
Commonwealth of Massachusetts Official Use Only
-
Permit No.
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: [,n r- l % Z -C 12 -
City
LCity or Town of. NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number)y ?- 1111cq a w r
Owner or Tenant ,'c /1 A - o left Telephone No. G / 7 Cc,/ —S9gg y
Owner's Address
Is this permit in conjunction with a building permit? Yes [& No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑
New Service Amps / Volts Overhead ❑ Undgrd ❑
Number of Feeders and Ampacity
No. of Meters
No. of Meters
Location and Nature of Proposed Electrical Work:
Completion of the following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil: Sus (Paddle)Fans
p•
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In- ❑
rnd. rnd.
o. o Emergency Lighting
Battery UnUn iists
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of and
No. of Switches
No. of Gas Burners
InDetection
Initiatin Devices
No. of Ranges
Tot
No. of Air Cond. Tons
No. of Alerting Devices
Heat Pump
Number
Tons
KW
No. of Self -Contained
No. of Waste Dis osers
P
Totals:
....................... I
.......................
Detection/Alerting Devices
No. of Dishwashers
S ace/Area Heating KW
P g
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Y
Heating Appliances KW
Security Systems:'
No. of Devices or Equivalent
No. of Water KW
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of wires.
Estimated Value of Electrical Work: "3 a a (When required by municipal policy.)
Work to Start: Z d jtsve 1 L Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify, under the ains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME:. av 4F.5 Gt/G o h LIC. NO.: 11,
Licensee: av c k f 1./c /)(-C.% Signature LIC. NO.:
(If applicable, enter "exempt" in the license number ' e.) Bus. Tel. No.:
Address: CIZ Z- t'V A Puff e+w �+�✓ �, � �/%.� Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Departmenvo5f Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent PERMIT FEE: $
Signature Telephone No.
r
.. J�'J.1lJ�t�.l..�i-I.��tH�'!'�lt.�C-(�r�yys��.i�.'1.�iJ.�JJ�.�!.Ql�®p'.'�i'ppt ry-t �13'�.fru�.lCl.'I./rl�( �®�.1.: � • _
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�sts�ectax's' comments;
(fiis�ectors' Oignatu a .-.to Wiials)
:fns�ectioxt�'e0t�ixeci($�0.00)wT � ..
Slate
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(rtospectoXs'Signaiuxe�aoiniaTs) Pate .
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asseci—T � �'ailec�--T � ` �e-�ns�►ectionxequixe� (�50A0) � T � '
ts,�ectbrs' eoznmeptfs.
(Zuspectoxs'�`zgaaiuxe�xiojnitiaTs) date
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pectora' corhm.ents; -
_ �1;�sp ectors' �ignaiuz'e � xto initials) date '
J)OP, TA,(9,5 AM TO33F,)'IfTED OlI IN -'T OX 191TE IN
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Invesfigations
600 Washington Street
Boston, MA. 02111
UV www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeLyibly
Name (Business/Organization/Individual): Davi �Q f S, t✓ G f' fc �+
Address: q Z Z- �✓� �„ ��/ ��
City/State/Zip: L, w f , r 0, ,4a a/ fi 7 6 Phone #: Q 7 r Q' 7 3` 3.30- t/
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
Z&1am a sole proprietor or partner-
listed on the attached sheet. I
ship and'have no employees
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.]
officers have exercised their
3. ❑ I am a homeowner doing 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. F1 Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. El Electrical repairs or additions
11.0 Plumbing repairs or additions
12. ❑ Roof repairs
13�ti�sr
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
i Homeowners who submit this affidavit indicating they are doing all work and then 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.
lam an employer that is providing workers' compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name:.__/pr� err •a/ iL% fv.
Policy # or Self -ins. Lic. #: CoOf a//a 6 O 2S C/ / Expiration Date:
y Job Site Address:c% ,,41ywo% D r, City/State/Zip: ; ole • r �t/%dt
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 DTA for insurance coverage verification.
I do hereby certi
fy under/the pains andpenalties ofperjury that the information provided above is true and correct.
Signature: �i1 Date c I %2 r /
471 -33a V
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 -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. AIso 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 bum 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, MASSAFB
Revised 5-26-05 Fax # 617-727-7749
www.mass.govfdia
Date.. ......
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that
...................................
has permission for gas installatiow. ........
in the buildings of . . ................................
ateel
........... North Andover, Mass.
Fee -f...... Lic. ..........
GAS INSPECTOR
Check
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
_ l
G
Kb An d ova:r , Masse Date 1 AD9_
City, Town Permit #
Buildingi Owner's
AT: Location FMP ou) kd Name �0
164
Type of Occupancy : F-oj i ai )ce,
New Renovation ❑ Replacement
Plans Submitted Yes No
(Print or Type)
Installing Company Name ' �oI_d eo -0j I nr .
Address Q l I (.Ie -*Id e -p+
Pe(]�ndL4 ma a q u a
1)0 Business Telephone H t– 56 1—
Check One:
f ' Certificate
21 Corp. `
❑ Partnership _
❑ Firm/ Company
Name of Licensed Plumber or GIsfitterL
I hereby certify, that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent
provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
I have informed the owner or his agent that I do not have liability insurance including completed operations coverage.
Signature of Owner/ Agent
I have a current liability insurance policy to include completed operations coverage. ❑
B
Y TYPE LICENSE:
Signa ure of Licensed
Title ❑ Pjninber Plumber or Gasfitter
City/ Town 9"'Gasfitter
APPROVED (OFFICE USE ONLY) ❑ Master f
❑ Journeyman License Number
FORM 1243 A.M. SULKIN CO. 1989
MENEM
(Print or Type)
Installing Company Name ' �oI_d eo -0j I nr .
Address Q l I (.Ie -*Id e -p+
Pe(]�ndL4 ma a q u a
1)0 Business Telephone H t– 56 1—
Check One:
f ' Certificate
21 Corp. `
❑ Partnership _
❑ Firm/ Company
Name of Licensed Plumber or GIsfitterL
I hereby certify, that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent
provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
I have informed the owner or his agent that I do not have liability insurance including completed operations coverage.
Signature of Owner/ Agent
I have a current liability insurance policy to include completed operations coverage. ❑
B
Y TYPE LICENSE:
Signa ure of Licensed
Title ❑ Pjninber Plumber or Gasfitter
City/ Town 9"'Gasfitter
APPROVED (OFFICE USE ONLY) ❑ Master f
❑ Journeyman License Number
FORM 1243 A.M. SULKIN CO. 1989
a
a
m
r
z
P
2
0
T
m
m
r
r -
* ' The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
^M 5www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Legibly
Name (Business/Organization/Individual):� L 17 et"/� ®1
Address: 91 1 y/wv r1t: Z6 �,57k€F-7'
City/State/zip: '�`�t4 L3 o y , /1419 p ` Phone #: 97L531' ajr
Are you an employer? Check the appropriate box:
1. P I am a employer with q5
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet. $
ship and have no employees
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.]
officers have exercised their
3. ❑ I am a homeowner doing 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
8. ❑ Demolition
9. ❑ Building addition
10 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
*Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information:
t Homeowners who submit this affidavit indicating they are doing all work and then 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.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: UJ1 /l)1FS Ai ScJ�Pu ��es CchYr n�s�T,.» C �,o
Policy # or Self -ins. Lic. #: 1niC 0003 i4q — 4/ Expiration Date: _ 01/o, /aoco
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Faihire to secure coverage as required under Section 25A of MGL c. 15cr
2 can lead to the imposition of iminal 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 certify under the pains and penalties of perjury that the information provided above is true and correct.
Phone #: 67 79— 3/ - 03,9 L�
Orkial 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 f -".
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 ofpublic 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. 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 afthe bottom
of the affidavit foryouto 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 bum 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
Revised 5-26-05 www.mass.gov/dia
O
ti
SACHU
%.1 ..tO..-
........................
Date ... X
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
TThis certifies that .............-.......................... .....................................
has permission to perform .......0(G ...... . . .......................
wiring in the building of ......... . r.46.-1 ...................................................
.:P, rz
at ......... e:--.' .... ..... /?........North Andover, Mass.
Fee...r..�..74-- Lic. No. ......... SPE
CrO
L
Check #
9'1 05
Commonwealth o f Vamackwetb
e1 part.d o f aim S.Mice4
BOARD OF FIRE PREVENTION REGULATIONS
Official
�Use Only
Permit No.
Occupancy and Fee Checked
[Rev. 1/071 leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 41) 2, 6 o g
City or Town of: Ado VAr To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention o perform th]ectrical work described below.
Location (Street & Number) F. -F- � `/' �qeq Clm U1 e �
Owner or Tenant
Owner's Address
Telephone No.
Is this permit in conjunctio with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building S 1 ev LO Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Elecal Work: _&-94-0-
Telephone
GSC
Completion o the followingtable ma be waived b the Ins ector o Wires..
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans
s Total
of
TransKVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In- 1-1o.
rnd. rnd.
o Emergency Lighting
Battery Units
No. of Receptacle Outlets
o. of OilBurners 4e
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
Detection and
No. In
nitiatin Devices
No. of Ranges
g
No. of Air Cond. Total
Tons
No. of Alerting Devices
Heat Pump
Numerb
Tons
KW
No. of Self -Contained
No. of Waste Dis posers
p
Totals:
.........
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑Other
Connection
No. of Dryers
i y
Heating Appliances KW
Security Systems:
No. of Devices or Equivalent
No. of Water Kms,
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
GG Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Valuef,9�f Electri al ork: N Le) (When required by municipal policy.)
Work to Start: C K Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVE GE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that suc coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) 7, C4r/ L X �S L��G w,9
I certify, under the pains and' enalties of perjury, that the information on th' application is true and complete.,
FH2M NAME: t44, eS L L -D /l q LIC. NO.: ,(!� 13 [' 15
Licensee: Signature 1•-- LIC. NO.:
(If applicable, enter "exempt" in the license number linen �/J 1 L Bus. Tel. No.: 97�r - lF-� %
Address: �i 1� PX -k-2 e;: /"l _� !'t Aft? a��/ / Alt. Tel. No.:
*Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's a ent.
Owner/Agent PERMIT FEE: $
Signature Telephone No.
Location
No. .5-3 2 Date 12-1231Y
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
1 �r i T✓ L Other Permit Fee $ 2-
-5
5 Sewer Connection Fee $
Water=Sonnection Fee $
RECE VED P TO AE
TOTAL
DEC 2 5 1991
Building Inspector---/
G/
Nlo. Andover
Div. Public Works
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