HomeMy WebLinkAboutBuilding Permit # 6/4/2015 VAORTfHt
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received
C US
Date Issued:
IMPORTANT:Applicant must complete all items on this page
LOCATION 27 Morol'oj 5'iIefe Lvt ,
Print
PROPERTY OWNER, 4 P\1 I -/I��q
Pirint I 00"Year Struc,t6re yesno
MAF PARCEL: ZONING DISTRICT: Historic District,'" yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building El One family
11 Addition 0 Two or more family [I Industrial
11 Alteration No. of units: 0 Commercial
El Repair, replacement El Assessory Bldg N Others:
El Demolition 4k0Cher 7Y,% ox I
qt
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: ri/o ki 9-e1 7-0 Phone:
Address: ;k-:F Ma r,%A Let a 5 P"Je
'Contractor Name: tb14A-c Phone: 1;>Y-Ye)?- 7 G-S
Email:
Address: 2 e-IV3 vp rlA ;r 7- P hk i'57`
fIF
Supervisor'&Construction License: e4;t 1a6v 1 2 Exp. Date: 1/� h-&
Home Improvement License: /0>- Exp. Date: XA/h014
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.
Total Project Cost: $ .2 qQ0 .0 0 FEE: -3-5—1XI
;�7 e' /
Check No.: ` Receipt No.: :� P
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
- A I 17--l-I
tk®RTH
It own 01 Andover
® ;� a
No.
C._*
h )r
V� i)SS
® COC NS C He wicK
U
BOARD OF HEALTH
Rm m Mir inPE MIT LD
Food/Kitchen
Septic System
THIS CERTIFIES THAT ....... .A; !�l'-f.5�......�� .� � �.....:...... ...............'................................. BUILDING INSPECTOR
has permission to erect ..... buildings on �r�n r��i'y�.5 G�E....... Foundation
Rough
tobe occupied as ...............................:......�... ....�............................................................................. Chimneyy
provided that the person accepting this ermit shall in every respect conform to the terms of the application Final
"
on file in 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
EXPIRESPERMIT IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION ST Rough
Service
..................... ............r�rs. � ./ ....
�.r..... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathingor Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
..w , ..�
Federal ID#
JUST: rout;ineering RI Contractor Registration No
MA Contractor Registration No
A division of'I'hlclsch Engineering CT Contractor Registration No
60 Sltawnnrt unit 112,Cantoo,MA 02021 pLWT
RACT
66��
339-502.6335 FAX 339-502-6345
Dago 1
PROGRAM
71115 CONTRACT IS ENTERED INTO GET WEER FUSE
E" .iI EE I1 C✓ CNIA-1"IES ENGCRIBE
INEERI p 14D HE CUSTOMER FOR WORK AS
OW
CUSTOMER I+IIO}1E PATE CLIEttTd WORKO 'R
Alissa Evan'lelista (978)726-1210 02/27/2015 413 49
m � m +
..StSERVICESTI7EET _... _._.. pILLIN6 STREET
28 Morningside Lane 28 Morningside Lane �0 1mW0110"
10
SERVICE CITY,STATE,ZIP UILUN4 CITY,STATE,Z1P� 00
North Andover,MA 01845 North Andover,MA 01845
JOB DESCRIPTION
o
BARRIER:We have discovered what appears to be it mold/anildew-like substance in your honte.'rhis is being brought 1 11
attention to identify it its as pre-existing condition it)the insulation and air sealing work planned for your ironic.Your signa )rc is 000
your acknowledgcmcnt of these conditions and agreement to proceed.)SERVPRO.
HAS BEEN AT THE ROUSE T'O EVALUATED FOR MOLD MILDEW DUF TO ICL:DANUM NETD ALF.CLEAR FRC
ll IE!!!1*111,ROOFING CONTRACTOR MAY ADD Wl IFN RE-ROOF!!!
$0.00
Alit SEALING:provide Tabor and mmcrials to seal arcus oryour home against w°asteRd,excess air leakage. This work will be
perf'onaed in concert with the use orspecial tools and diagnostic tests la assure that your horue will be Ici1 with it healthful level of
air exchange and indoor air quality.Materials to he used to seal your hone can include caulks,f'oauns ami other products, primary
areas for sealing include air leakage to attics,basements,atuched garages and other unheated areas(windows are not generally
addressed.) (10)working hours.
At the completion of the weatherization work,oral at no additional cost to the homeowner,it final blower door and/or combustion
safety analysis will be conducted by the sub-contractor to ensure alae safety of the indoor air quality.
$750.00
DAMMING:Provide labor and materials to install;1 12"layer of R-38 unlaced fiberglass butts to(60)square Icet liar damming
purposes.
$123.00
ATHC FLAT:provide labor and materials to install a 6"layer orlt-21 Class I Cellulose added to(988)square feet ofopen attic
Space.
$1,185.60
$0.00
AlTIC ACCESS:provide labor and materials to insulate the back or(l)attic hatch with 2"rigid TTaennax board.Weatherstrip the
perimeter.
$60.00
VENTILATION:11rovide labor and materials to Install ventilation chuics in(28)railer bays to maintain air Ilow.
$56.00
VENTILATION:provide labor and materials to install(10) 6"X 16"rectangular aluminum soffit vents to increase ventilation in
anc,areas. Sl)ccil'y color:White or Gray.)SERVpRO.
ITAS BEEN AI'T'LIE ROUSE T'O EVALUATED FOR MOLD MILDEW DUE T1)ICE DAMS'!!NEED ALL CLEAR FROM
Tl ll'cl!!THE ROOFING CONTRACTOR MAY ADD WHIN Rl-It(: IT!
$250.00
BASEMENTCEILING:Provide labor and materials to install(95)linear feet OIT-19 unlaced fiberglass insulation to the perimeter
of flu:basement ceiling at aie house sill.
$166.25
BASEMENT DOOR:provide labor and materials to institute the back of the basement door leading to the bulkhead with 2"rigid
board than nnects the sections R-3111.5.4 and 316.6 requirements of building code. Seal all edges.rad scams with FSK tape.
572.22
Federal iO tl
RISE Engineering Rl Contractor Registration No
MA Contractor Registration No
A division of Iticisch Engineerhig CT Contractor Registration No
60 Shawnud Unit 112,Canton,NIA 02021 CONTRACT
,'„ 339-502-6335 FAX 337-502-6345
PBQB 2
PROGRAM
T 11 CONTRACT IS ENTERED INTO DETVIEEN RISC
ENGINEERING CMA-HES
ENGINEERING A140 OCSCRIDEDDELON/iIE CUSTOMER FOR tVtlRK AS
CUSTOMER PHONE DATE CLIENT WORKORDER
Alissa Evangelista (978)726-1210 02/27/2015 413649 0(
SERVICE STREET SSSS., ........ .BILLING STREET. SSSS SSSS �Op
SSSS
28 Morningside Lane 28 Morningside Lana
SERVICE CITY,STATTAT E,21p DICING CITY,STATE,Zip �
North Andover, MA 01845 North Andover, MA 01845
"o
JOB DESCRIPTION
�00000000'0 '40,
exterior overhang located below a heated floor arca,by drilling holes in the overhang from below. doles drilled will be plugg 'l N ""
OVERHANG:I rovlde labor and materials to insttai 10"R-37 densel° (eked Class I Cellulose insulittion to(3(3)sl care Ice f �
00,00
Plugs will be scaled with exterior gradc spackle and lefl In t1 relatively smooth condition.Finish sanding,and touch-up "1
priming/painting will be the customer's responsibility.
11110100
d $152,(10
RISE Engineering will apply all applicable,eligible incentives to this contract. You will only be trilled the Net amount. Currently,
for eligible measures,Columbia Gas(afters 75%incentive,not to exceed$2,000 per calendar year,and an incentive of 100%)for the
Air Scaling measures up to the first$600 and an additional$300 if savings are justified by the auditor.
For the safety and health of your home's indoor air duality,we will be conducting a blower door diagnostic of the available air flow in
your home both before the work is begun,and alter Ute weatherization work is complete.We will also conduct a hill assessment of
the combustion safety of your heating system and water heater.This has It value of$90 and is tit no cost to you. Total allowable
weatherization incentive is$2,990.
$70.011
Total: $2,908,07
Program Incentive: $2,388.80
Customer Total: $516.27
WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF
***Five Hundred Sixteen&271100 Dollars $516.27
UPON FINAL INSPECTION AND APPROVAL BY RI ENGINEERING,CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL.INTEREST OF 1%WILL BE CHARGED MONTHLY ON ANY '..
UNPAID DA AFTER JS PAYS.SEE REVS E FOR IMPORTANT INFORMATION ON GUARANTEES,RIGHT OF RECISION,SCHEDULING,AND CONTRACTOR REGISTRATION.
_SSSS ....._ ....... .::_..___. ... SSSS. _.._.... ......._ .. ......_. .. SATS.. .. SSSS ASST.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES _
A 1 (ZED SIGFIATo E RISE EnDi ..dap SATS ._. ...,. .. .. C011-1 01MER ACCEPTANCE
NO TE:THIS CONTRACT AAT. •WITHDRAWN BY USIF NOT EXECUTED WITHIN DATE OF ACCEPTANCE
ACCEPTANCE OF CONTRACT-THE AGOVE enicE$,SPECIFICATIONS AND CONDmONS ARE
30 GAYS SATISFACTORY TO US AND ARE HEREBY ACCEPTED,YOU ARE AUTHORIZED TO DO IRS VIORK
AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE
0
AUTHORIZATIONOWNER
I, I ~ ,' {
(Owner's Name)
owner of the property located at
c� - rdeJLW .
UP
rop6dy Address)
01.0
(Property Address)
hereby authorize000
(Subcontractor)
an authorized subcontractor for RISE Engineering,to act on my behalf to o in a bullcn�
permit and to perform work on my property. °
................
0 er's Signature
Date
`\ The Carrrnronweaffli of Massachusetts
Department of Industrial Accidents
'•_;: + *-= Office of Investigations
600 1-Mashurgton Street
Boslon, MA 02111
tvivtv.rlrttss;ov/ilei
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le;ribh
Hanle (Business!Organization/individual): ® 11ti— A eak r rAS.114Y'toV v `1"/ _
Address: 0 k _f
City1State/Zip: jkoL Phone#: _ �- /
FS
Are you an ernplo�yero Check the appropriate box: "Type of project(required):
1. I am a employer with 4- ❑ 1 am a_general contractor and I 6 E]New construction
employees(fill and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. [:] Building addition
[10 xvorkers' comp.insurance comp. insurance.'
required.] 5• ❑ We are a corporation and its 10.0 Electrical repairs or additions
3_❑ I am a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions
myself.[-No workers-comp. right of exemption per N4GL 12.[] Roof repairs
insurance required.]' c- 152- §1(4),and we have no
employees. [.No workers' ]3.&Other
comp. insurance required.]
.*Any applicant that checks box#I must also till out the section helow showing their o-orkers compensation Polk-inronnation.
r l tomeowners who submit this affidavit indicating Arcy are doing all nark and then hire outside contractors must submit a nen-affidavit indicating such.
{Contractor that check this box must attached an additional sheet showing the name of the sub-contractors and state n-hctheror not Arose entities have
employees. if the sub-contractors have employees.they must provide their Arorkers-comp.policy number.
l to»an eniplojtor that is providing(porkers'compensation utsitratrce far nth'eniplol-ees Below is the polio'and job site
information.
Insurance Company tame: �� /1 Q r
Police 9 or Self-ins.Lic.;: ® VJC— &b Expiration Date: l ® /�
Job Site Address: City/State/Zip:
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 S 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 S250-00 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.
1 do hereby certif-tinder the pains andpenalties ofperjuo,that the informatioit provifled above is trite and correct
Signature: v Date:
Phone k 7- 24
Official iise oali= Do not tprile M this area,to be completed bl•eitV or fowit official
City or"Gown: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk -t. Electrical Inspector i. Plumbing Inspector
6. Other
Contact Person: Phone#:
A � `TI 1 T I ILJ 1 p0110812016
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 Ileu of such endomement(s).
PRODUCER NAME:
Automatic Data Processing insurance Agency,Inc. ac°NE E:d:
4 Ad)r Boulevard nonRs:
Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAICO
INSURERA. NorGUARD Insurance Company 31470
INSURED POLAR BEAR INSULATION CO INC INSURERS:
51 S CANAL ST INSURERC:
PO BOX 958 INSURER D:
Lawrence,MA 01843 INSURER E
INSURER F:
COVERAGES CERTIFICATE NUMBER: 295670 REVISION NUMBER:
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 —POLICY EFF POBUTEKV
LTR TYPE OF INSURANCE p POLICY NUMBER MWD LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
DAMAGETGRENTEU
CLAIM"ADE D OCCUR PREMISES Ea ocamence S
MED EXP(Any one person) S
PERSONAL 8 ADV INJURY S
GEUL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY❑
PRO-
POLICY F-1 LOC PRODUCTS-COMPIOPAGG S
OTHER: LIMITS
AUTOMOBILE LIABILITY l:s,"ydent INGLE $
ANYAUTO BODILY INJURY(Perperson) S
ALL OWNED SCHEDULED BODILY INJURY(PeraWdeni) S
AUTOS AUTOS PROPERAG
TY DAME S
HIREDAUTOS AUTOS Peraoddent
$
UMBRELLA LiAB OCCUR EACH OCCURRENCE S
EXCESS UAB CLAIMS-MADE AGGREGATE S
DED RETENTIONS S
WORKERSCOMPENSATIONff
ANDEMPLOYERS'LIABILITY SE TATUTE ER
A ANY PROPRIETORIPARTNERIEXECUTiVE YIN E.L.EACH ACCIDENT S 1.000.000
OFFICERIMEMBER EXCLUDED? Y�NIA N POWC660990 01/0112015 01/01/2016 1 000 0
(Mandatory In NH) E.L.DISEASE-EA FMP1 OYEE S
uyes dam1m under 1,00000
DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT S
DESCRIPTION OF OPERATIONS 1 LOCATIONS l VEHICLES(ACORD 101,Additional Remarlm Schedule,may be aUached If roma space Is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
CPLUMBIA GAS ACCORDANCE WITH THE POLICY PROVISIONS.
195 FRANCIS STREET
Cranston,8102910 AUTHORIZED REPRESENTATIVE
A®1988-2014 ACORD CORPORATION.All rights reserved.
ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD
OP 1Do SS
CERTIFICATE OF UABILITY INSURANCE
THIS CERTIFICATE ITS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS N®ROM UPON T1tE'COMMATE HOLDER. THIS
CEITMCATE DOES NOT AFF1111MAWELY OR NEGATNMY A1), MMD OR ALTER THE COVERAGE AIWORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DNOT CONSTITM A CONTRACT BENG WSURERMA OR
REPRESENTATIVE OR PRODUCER,AND THE COTTIFICATE HOLDER.
IMPORTANT: If the holder is an—ADDMONAL INSURED,the poffcy es)must he endorselL 1f S1.18 TION 18 WAWA eub to
the terms and conditions of the policy,carrtatn policies may require an endotsemmiL A stutemat an this CeMcM dues 000 counter tights t0 the
cermcat a holder in Lieu Of Such mcdorsement(s
PROBUCER CONTACT
D A J N ft AgE LLC P olm
am,MA 01845
DursoNorth&Jankowski Ens.Agoy. Poasl� P® '1
1l M0 AFMRI3MQ NERAGE HAID8
MURM Polar Bow Insulwon 0.Inc. MUMA.PennAmerica am
P® 955 1HBU=B,8a1W insurance Co. Ilme
Andover,MA 01810
1u1aERc:
amuRmo:
IcasuRlar+e=
1N9URER F
COVERAGES CERTIFICATE NUMB EON NUMBER:
THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE
FORINDICATED. NOTWITHSTANDING ANY REQUIREMENT TERM OR CONDIETON OF ANY CONTRACT OR OTHER DOCUMENT WITH-RESPECT
�.TOEIROWHICH THIS
CERTIFICATE MAY BE ISSUED)OR MAY PECrPJK THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONOITEONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
TYPEOF Pony I-PaLmom
umm
GENERALLUumm EACH OCCURRENCE 5 11,000,00
A COM1X13iCUI4 GENCR2A1.LiABIUTY PA O 15 6 pRE6TiS6 oaaur S Sa3
G(A[M a MADE®OCCUR MED EXP(An one iersm S 510
00
PERSOry mADVINJURY S 1,000,0
GFNERALAGGREGA7E S 2080100
GENLAGGREGAATEUMRAPPUESPER PRODUCTS-coU IOPAGG S 1.000.00
POLICY P LOC $
AtROMOBILELUU31LF V ComemoSINGLEUMIT S 13000,00
ANY AUTO 10Q9� 501 s BODILY INJURY(Perp ) S
AU.OINNEDAUTOS BODiLYINJURY(Per aacafto S
X SCHEDULEDAUTOS PROPERTYDAMAGE S
X HIREDAUroS (PERACCIDENT)
X NON MEDAUTOS S
S
UMBREU.AUABX otxUR EACH OCCURRENCE S 1,000,0
E XCOS LiNCLaMs MADE PA =24=5 6 AGGREO we s
' DEDUCTIBLE $
RMWION S S
WORKEWCOMPEmirmn STATU•
AND ENPLOYEW L(AaIInY
ANY PROPRIETOWYIN E.L EACH ACCIDENT $
OFFICBt1t num EXCUL DE0? ® N/A
(yy8eaa,�1►[nNH) E.LDiS£ASE-FAEMPLO S
DESCR1PT1ONOOFOPERATIONSWov EL.DISEASE-POUCYUMTT S
O iP1[ON FOPF-AA OISB/LOCAl1 / (A CORDIQT,Ad�ffiI ttmommmigr
Inssuu allan Var�c..�itterel;Aa� IU dor a rai 1�i
r. N4o work perfu d OWNS be by ve�nlau s ielsch
n nave ng
CERTIFICATE HOLDER CAN TERN
'fHl
SsWULD ANY OF THE ABOVE OEGCRUSED POUCMO BE CANCFI I Cpf BEFORE
TIM RDTPSoSE WILL BE ® LVERED tN
Thi h Engl rng CCOflDANCEW H THE POLICY THEREOF,
®
Columi la Gas
195 Francis Ave AUTHORIZED REPRESONATINM
Cranston,iii 02910 —AA9k
0 ESB-2 ACORD C®RPORA-nON. All dghts resme&
ACO D S5( g) The ACORD name and logo are registered maft of ACCORD
•airs andZiness Regulation
Office of Consum�kaza- Suite 5170
10P
Boston,Massachusetts 02116straticn
Bone Improvement on Reg Registration: 102726
Type: DBA Tr# 252249
Expiration: 7/212016
POLAR BEAR INSULATION Co.
Vincent LeBlanc
P.O. BOX 958 ----
ANDOVER, MA 01810 -
Update Address and return Car ploy reason 0f Lost Card
i Address D Renewal
OPS.CA1 ca 50M-04104-G101216
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toabd of BB ,sa kjin g Rea,jkflations and , ttan aka,s
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C+SQL-106017
PETER A LEBL,ANC
2 EAST PINE STREET
Plaistow NH 038455
°f 0412812018
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