19 ROCKDALE AVENUE - BUILDING INSPECTION s
i
Commonwealth of Massachusetts
Board of Building Regulations and Standards
Manufactured Buildings Program
-. THIRD PARTY INSPECTION AGENCY CERTIFICATION
BULK LABELS
This Section to be completed by Third Party Inspection Agency-Pease print or type-UNITS MAY NOT BE
SHIPPED UNTIL THIS CERTIFICATION IS COMPLETED and COMPONENTS ARE LABELED
SECTION 1-MANUFACTURER INFORMATION (S\M£g\mfgthirdpartycert buwabels2005-July,2005)
Manufacturer Name Customized Structures Inc. MC# 032
Address 272 River Rd Claremont, NH 03743
Telephone 603-543-5300 Fax 603-543-5396
E Mail Address bobjohnson@customizedstructuresinc.com
SECTION 2-BUILDING INFORMATION BBRS\DPS I.D. # 0946-05
Street Name&Number 19 Rockdale Ave
City Salem State MA Zip
Use Group R4 Construction Type 5B
In signing this form below, I hereby certify that the units identified on this form have been inspected and
are constructed in accordance with the following codes, as applicable.
Massachusetts State Building Code (780 X Massachusetts State Electrical X
CMR) Code(527 CMR 12)
Massachusetts State Plumbing and Fuel X Massachusetts Architectural Access X
Gas Code (248 CMR) Board Regulations (521 CMR)
Mfg. Plant Inspector's Name (Print Name) Third Party Inspector(Print Name)
Robert O.Johnson TPIA#: 02
Mfg=ature ' d P Insp r' ignature
Date: 7 Date:
SECTION 3- LDER/DEALER/CERTIFIED INSTALL ORMATION
Builder/Dealer: Templar Homes
Address: 174 R Lynn St Peabody, MA
Licensed Construction Supervisor: License Number: 19737
Certified Installer: Bud Morin or Kevin Whitney-Crew Chiefs Exp. Date: 8/18/07
SECTION 4-LABEL INFORMATION(Indicate number of boxes and number of labels required)
Number of Units 2 Label Numbers Issued: 99198-99199
Manufacturer's Serial Number: 054120
Manufacturer's Model Designation: Split-Entry
The original form shall be mailed to the BBRS/ Department of Public Safety
167 Lyman Street/P.O.Box 1063 Westborough,MA 01581 kimberly.spencer@state.ma.us