400 HIGHLAND AVE - BUILDING INSPECTION (6) . '
� � �The Cummunti'�ulth uf Mussuchusrus ;
IUR
. � y 13uard uf BtulJing Rcgul:itions and StanJards � pil'VI( IP.\I I Il '
t '`Y ,; Massuchusct:5 Staht ljuilding ('ude. 78U CMR. 7a� r�itiun �
� i�..:�,i - I�.til'
, 1 [3uildin� Permit Applicatian To Consvuct. Rep�ir. Rzno��tr Or Drmulish a /l��i,�J J<,��u„r� �
.. \ . /. 'unJ, i
� Onr- ur T�ru-Fumilv D�rrlliii,4
� - Th� � . ectiun F� r Officiul Use Only
, � Building Permit Num er.� Date �pplied: ----_ I
s���,:,��,r: � 3 � -------- 1
ftuildinfCummi+siun � n.perw (Bu �s U�tc �
tiECT10N 1: 51TE INFORM<A"PION �
ILl Pruperty :lddress: 1.2 :�sseuurs blap & Parcel Vumbers
I _400 Hi hland Avenue S #13-#14 __ __ 03-0005-0 __
g_-- a__1Qia._MA�1410--
Ala Numbrr P:urcl \'wnbcr __�
I.I i Is thiti .in acceptcd ,trreC? vas X no_ ' P _
L3 Zoning lnfornwtion: IA Property Dimensiuns: ,
3200 sq. ft i
-__-__- -_---— _ _. ___
� Z.�ning Gi�t�lei Prn�.a;rd Use Lo� ar..i�sy i'U t�i�>nin�c�,'i� ,
F------- -- -�� ----------------------- �
I 1.5 Bui!de�� Seibacf:s (1't;__ ._ . --- -. _� I
f -
� F-uut Yart� .____.-_� - —SiJe \T�c!. __ ___Rc�r 1'ard
�. — -- ___-- _
� Naywrcd � Pro ��ded 1 2eyw�ed Fr ��dzd i R . . iirrd i Piu: .. . � i
_.. --_ _ - � _.. . ..-_ ___
. —_-+_ � . � . � � ._. _ J
I I i._. -
r Lfi ��'�ler Supply Iv��;.i.c.�a0. §51� � ! 7 Flooh L.on� Info�m�tu �:---- t h S N.:g¢?tt»posr! Syslu . �
I Fuhlic ❑ � Pri �ate❑ — j �'n� .— Out<.we Flnr�d Zo�c' y1umi.�pal O ��n �it d:ipr. � I ti �-e.n ❑ �I
_� Chcck .t y..aJ
r ----- —� SEf.TfON 2: PftOPLRTY OV4NERSHIP� --�
� 2.1 Owner�of Rrcoed: ------- -- -- - - �
400 Highland Place Realt Trust_____._ _142Pleasan.t Sr*PPt_Maar.hLekiead�_.MA._D39A5---- �
�
I iV.ime fPrintl � Addre:s For Serviee:
I __ ___--_ ___. _____-... 781'631'3070 ____ — _- I
j Signaturc ___ ______.-_--- Ttlephun________ - i
---i
I SEC"f10N 3: DE:S('RIP77Q[< OF PRO}'OSED 'WORK2(check nll [hat apply) ;
L— -- -
--r----------�---- . --r--�-----�
�New CunstrucU��n O Eri.;rin� Building Lf Owner-0ccup�ed ❑ Repuirs(s) ❑ r�l:er:�uon(s) C% i Adchu��n ❑ �
------- -}- -- ---1---- '-------
Demolition ❑ A�:ce,.sury Bidg. O I Numbe� uf llnits_--- Gther f7 Sperily:--_=----,---- _.__�
�--- -
F3riei Dcsrriptiun uf Proposed lklirk`: TntQ�,-r;r;�..����y��----------- �
--- —
--------------- -- ----- -- ----..._- -- I
;t — _ i
I----- --- --------------- �--------� .
-------SECTif3\ 4: F_$'�'rYh7'EL (:t?iV57'k'.i �'i'li?>! i:t:STS __�
i-- — Es imute.d Cotit�---- '-'— �--'- ------- ..�
� [ie�n _ i[ �'n � mu M�tuial�l �- nf�ci:�l Use Only ---
�--- - -- — - --- ,
I. llud:fine i 'S I. Buildin� Permit f u 5 . � Indir.�te huw- fec i.�u�r���i�:ic.,. '�,
--+--- O Standard Ci[y/l�u�v�i ;\pPlic:itiun Fee
� 2. Fleclrical j � 2 504'�00 � ' - ' ----. '.. . .
._:_. O Tot�l Pruject Cost� ttiam 6; x ;,iwtipliu__ s
..�-Plumbin� ----- � 3. Other Fees: $ _ � � _ �
LisC
� -t. �til�rhanical IkIVACI 5 � ---- �
�. Mech:micul fFire � ---- ��
Su restiiun) Tut:il All Fers 5_ __
� ChecA Nu. Chzck :\muunt (':uh :\m�wnc _ i
� 0. Total Project (;os[: $ � �;,JO�/ ❑ Paid in Full ❑ Outst:uidin� Bal:mce Dut:------ - I�
--�
i � �-
c�-� ,�� ��J '
� �/ �p
a--�
�
� � 1
SECTION 5: CONSTRUCTION SERVICF,S
S.l Licensed Cunstruction Supervisor (CSL)
78214 3 11 10 __
Richard Rockett Lircnsc Ni�inbtr G�pir:iti�iu Dalr
���
� Name ul CSL- IluWer
Lisl CSL'P�pe l<cc bclu'�v)
4 C1i�QY W3y M hl h aA MA OlQLS �
� 1 re. �//J L� � T '�� _ Ucscriniun ,
� � C/��� I��-F-�/vl L� l�nrc�u�IctrJ �up to i5.UU0('u. fi.i � .
� � �" R ^cstrirlcd I�i' Famil�' Du.•Ilinc ..
Si@naturc �l �lusonry Unh� ' �
, 781-775-8605 --�—`—�—""
RC Rrsi�.lrmial RnoiSng C'o�rnne I
Trlrphunc \�5� Re�i�lin!ial \tiindu�.c .indSiJin� _
SF Rr.iJrnti:J Soii� Purl Burnwe .\i���lianr: lu�i.ill.w��ii� �
U Hc�i�cntial Ucniuhuun � .
5.2 Registered Ilome Improvrmen[ Cuntr•rctor IFIIC) �I�
HIC Cumpany N�mc ur HIC Rcgisir�nt Nanu � Rcgistralion Numbcr —_
� Addre�s — --. —
I .--- — — G.ep�rauun Datc
� :,ifnawrr - '1'elrphunc -- ----�
F_-._--"------� _ �� ....�-�....� ..,c.ro.n�r-F ��c n� '+ i ,
i SF'.C"PtIDN .',: 'tiVU�:I�i:idS` CGir"se �i�ar..:._a�. .,...,,...:..�_.,. . 1.,. VfT (ti1 Gl�. c. 152. § _SC(h)i �
-- -- - — �
�^�orkers C,�mD=nsati�m fosur�ncz af(�id�vi[ mus[ be cumplered and submitted with this appiir;�ti�-�n. F:iilure tu pru�idc �
� this aftidtvii will r_sult iri �hc denial of the Issuance of�he buil�in� perrnit. ' � �
...------'----- �----- ---�---_-._. �
Sitnerl Aftidac;t Attached'? Yr;. .......... � No ......._.. ❑
--'-- ------ -_._..--....--- --- -� . .
SECTI13iV 7a: OR'NER AUTFIORIZATION TO BE COMPLETED WI:�N• •- - i
UWNE�d'S AGEN'd'OR CONTRACTOR APPLIES FOR BUlLDING PERMIT _ _�
I ;._Richard Rockett_ _, as Owner of the subject pruperty hereby ��
:w�huria.e Steven Spillane ro act un my behalf. in aIl m:iLers
relative w work authurized by this building permit application.
I
�S�nawrculOw�ie�� -- ------- Uat� --------- ---,---'
I SECTIOR; ib: CIWNER� OR AUTHORLZED AGENT DECLAR.4TION _)
= ----- - i
i � Steven Spillane , �s Qµ'ncr ur.4utiiorized Ageni hereby decl.ire '
� . ------- —
' ehnt the statements and informatiun un thc foregoing application are tr�e and accurate, to the best ot my Ano�vled��e and I
i
behadf. � �
. �-L✓� �' � I
Fnnt Vzme � 3 .L �� �
ISignature aY O:;ner or Authorized Agent � ��« I
' i�i .ned nn.ler G�e pairs and penaiucs of Perjur,�)
--____ _......_.______._...—.—__--___I
NOTES: '
I. An Owner who ubtains a building permit to do his/her uwn �+�urk, ur:m uwner whu hires an unre��istcred runtruetnr
(nut registered in the Hume Improvement Contructur (HIC) Prugraml, will ituf have .icress to the ;irbivatiun
progr�m ur guaranty fund under M.G.L. c. I�1'A. Other impur[unt infurmution on the HIC Pmeram :�nd
Construction Supervisor i.icensing(CSL)can be tiiund in 7S0 CMR Regulutinns I IO.kG and I lQRS, re,pecti��zly. I
. ; _'. When substantial work is planned, pruvide the infurmatiun below:
I � T����I flours area lSq. Ft.1 lincluding garage, finished ba�emenVatt�cs, derks ur purrh� �
� Ciruss living area i Sq. Ft.l_ _ � Habituble ruum ruunt __ .
Nwnbtr uf'firepl:ices ___ � Nutnber uf hedroum� __ ..
Nuntber uf hathrooms ___ Number�>f ha1�76:uh; _,_ , �
'I'ypa uf hzaiing system � Number uf darks/ p��rehe, - ---. i
'�ype uf cuulin� tiytitem Linclu:,td --- Upen -------
3. 'Tutal Project Square Fuotage" may be substituted fur "Tutul Pruject C��at" �
'
�=°�� CITY OF SALEM
�,}��, ' ' . PUBLIC PROPRERTY
��`�^—��� �� � DEPARTMENT
����m„
, �
�,;��s�-H��-:,��,H���„��.
, �L�r�.�K I}C\�'.�iiu��,n��Sn<ur:r � S:v.[��, �I.�,S:���rir�r�rr.J1970
�i'�°.�.: 978-7ii-9�9; � F:ix: 978-7�G-78�G
1Vurkers' Compensation [nsurance Aftidavit: I3uilders/Contractors/Electricians/Plumbers
� > >li��nt Information Please Print LeQibIY
V;till� 1���+intss�Organiz:vium'InJividu:dl: Villaee Co str� t' —�
A�IIIfCSS: 190 Pleasant Street �
�
CiryiState/Zip: Marbi Phone #:781-639-nn
:\re cou an employer? heck[he •rppropri•rte box: Type o[projec[(reyuired):
I.❑ I am a amployer with - 4. ❑ f ain a general contracror and I 6. ❑ New construction ��
zm lo ees(full anci/or art-time).' have hired the sub-cuntractors - , �
p Y P 7. ❑ Remodeling
2,❑ I un� a ;ole proprietor ur partnery � lisred on the attached sheet. � . . �.
ship and havz no employzes Thzse sub-contractors h�vz 8. ❑ Uemolition � �- �-.r�hcs
working fur me in any capaciry. . workers' comp. insurance. y. ❑ 6uilding addition -��
No workzrs' cum insurance 5. �� We are a corporation and its ���"�'
� P� 10.� Electrical repairs or additions � � ,
reyuired.J ofticers have zsercised their . � �,
ri ht of exem tion er MGL 1 l.0 Plumbing repairs or additions
3.❑ 1 am a homeowner doing all work � P P
nryself. [No workers' co�np. c. 152, §l(4), and we have no ��.� Roof repairs _.
insurance reyuired.] t employers. [No workers' 13.� Other -'9` "'
comp. insurance required.] .
•qny;�pplicmit Ihm checks box p I musl also till out the section below showin�Iheir workers'compensuliun policy infortnatioa �
�I Io�neuwners who suhmii�hi<:ifTidavif inJicxtinb�hey�re doing all work and tLen I�ire uutside Contractors must suhmit a new affidavi[indicating such.
�Conlracrors that check this box mus[mtached an aJditional sheet showing Ihe nume of Ihe sub-cuntractors and Iheir wurkers'cump.policy infonna[ion. �
/uin uir euiployer�hut is proviJing rvorkers'coinpensation insurunce for�ny eu�pinyees. Below is d�e polic•y unJ job site ��
injarmation.
Insurance Company Name: ,
, WCC5001342012008 Ex ira[ion Date:3/11/09
I olicy #ur Selt=ins. Lic. N: P
Jub Site AJdress: 400 Hiehland Av City/State/Zip: Salem MA 01970
Attach a copy of the workers'�compensatiun policy declaration page (showing the policy number and expiration date).
Failure to s<cure coverage as required under Section 25A uf�1GL c. 152 can IeaJ to the imposition of criminal penalties of a
tine up to S I.SOQ00 ancUor one-year imprisonment, as well :is civil penalties in the form of a STOP WORK ORDER and a fine
ul up ro 52�0.00 a �ay ugainst the viulatoc Be advised that a cupy uf this statement may be fonvurde�to the Office of
Investigalions of the DIA for insur,mce coverage vtritic�tiun.
/do kerehy�rrtiJ'p unJer d�e puins and pertul�ias of perjury diut!he informutirm provrded ubo.�e is rrvie und correct
5i n nUr � - .. ... Dat�.. JIL I Io0 �
I h it � I 6�—�.QJ'l— ���� .
O/)iciu!use oidy. Do imf icrite in lhis ureu. m be comvlered by eity ur rrnvn oJ'JiciuL
Ciry ur l�o�r'n: � Permit/License #
Issuing :\uthori[y (circle one):
I. Iluard of Health 2. Building Department 3. Citq/Pown Clerk �. Electrical Inspcctor 5. Plumbing Inspector
6. Other
Contac[ Pcrson: Phone tt:
Information and Instructions
� \I:u,arhu,�us Genec:�I L:nvs chapter I�? reyuircs all entpluyzrs to pro.�ide �vorkers' cornp�nsation for their employees.
� .a..,.,..�
Pur,u:�nt to this ,tatiitr. �n eurpl���'ee is �fetincd as "._acery per�on in the ser��ice uf siwthar under uny �ontr�ct of hire,
�.�press or implizJ, ural or���rittzn..,
:\n rnyrlo}�rr.is d�fin�d ;u "an inJividu�L partner,hip. :uwciaciun. corporatiun ur othrr Irgul �miry. or any nvo ur mure
uf the foregoing eng�ged in �juint<nterprise. and induding the lagaf rcpresrntaticas uf a deceasad cmployer. or the
rec�iv�r or trustee uf an indiridual, p;irmership, associatiun ur other legal entity, rmpluying employees. fiowever the
owner uf u dwelling house having nut more thun three apartments und whu msides �hrrein, or tha uccupant of the
J�calling house uf ano�her who zmploys person, to do maintanance, eunstructiun ur rcpair work on such dwelling house
or on thc gruunds or building appurtenunt thercto,hall nut because of;uch employmen[ be deemzd to be an employer."
�1GL chap�zr i�2, §35C(6) alsu states chat "e��cry state or local licensing agency shalt �rithhuld the issuance or
renewul of a license or permit to uperate a business ur to construct buildings in the common�realth for any
applicant who hrs not produced acceptrble e��idence of compliance with the insurance coverage required."
� A�Iditiun�lly, bIGL dvipter 152, jZSC(7) ,tares"Nzidier che cummomvealth �ior any of its political subdivisions shall
' tnttr inro any contract for d�e parlunnanee uf public work until acceptablt evidence of compliance with the insurance
requiremants uf this chapter have been presznted to the cuntracting authority." �
:\pplicants �
Please till uut the workers' compensation affidavit completely, by checking the boxes that apply [o your situation and, if
nacessary, supply sub-contractor(s) nume(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liabiliry Cumpanies (LLC) or Limited Liability Partnerships(LLP) with no employees other than the �
members ur partners, are not required to carry workers' cumpensation insurance. If an LLC or LLP does have
employees,a policy is reyuired. Be advised that this affidavit may be submitted ro the Department of [ndustrial .
Accidents for contirma[ion of insurance coverage. Also be sure to sign and drte the affidavit. The affidavit should
be retumed to the ciry or town that the applicxtion for the permit or license is being requested, not the DepaRmen[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-insurence license number on the appropriate line. .
City or Town Officials .
Please be sure that the affidavit is complete and printed legibly. The Deparhnent has provided a space at the bottom
of the aftiJavit for you to till out in the event thc Office of Investigatiuns has to contact yuu regarding the applican[.
Please be sure to till in the pertnidlicense number which will be used as a reference number. In addition,an applicant
diat must submit multiple permiVlicense applications in any given year, need unly submi[one affidavit indicating current
policy infonnation (if necessary) and under'7ob Site Address'the applicant should write "all locations in (city or �
town)." ��copy of Ihe aftidayit that has been ofticially stamped or marked by the city or town may be provided to the �
;ipplic�nt as proof that a valid aftidavit is un file for future permits or licenses. A new affidavit must be tilled out each
yeur. �Vhere a home owner or citizen is obtaining a Iicznse ur permit not related to any business or commercial venture
(i.z.�a Jog license ur permit to burn leaves ate.)said person�is NOT rcquired to complete this affidaviL / .
N
TI�e Oftice of firvestigations would like to thank you in aJ��ance for your cooperation and should you have any questiuns,
pla�se du nut hesimte m give us a calL .
The Dcp:�runent's aJJress, telephune �nd fax number. �
The Commonwealth of Massachusetts
Department of Industrial Accidents
Oftice of Investigations
600 Washington Street
Boston, MA 02l 1 I
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
�t"..;`J �-,6-�� Fa�c # 6U-727-7749
www.mass.gov/dia
��
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated•Empfoyers Insurance Company
Burlington, Massachusetts NCci No aosss
- (800) 876-2765
POLICY�NO. WCC5001342012008
PRIORNO. WCG5001342012007
ITEM
1. The Insured Village Construction Inc � ,
Mailing Address: Mr Michael Rockett Marblehead MA �1g45 F
190 Pleasant Slreet
(No. SUeet Town or City Covnly State Zip CoOe
� ❑ Individual� ❑ Partnership � Corporation ❑ Other FEW � 04-3241709
Other workplaces no[shown above: �
2. The policy period is fror�3/11/2008 �003/11/2009 12;01 a.m.s�andard�ime al lhe insured's mailing adtlress.
3. A. Workers Compensalion Insurance: Part One of�he policy applies lo lhe Workers Compensation Law of the states listed here;
MA
8. Employers Liability Insurance: Part Two of.the policy applies to work in each state lisled in item 3.A �
ThelimitsotourliabilityunderPartTwoare: BodilylnjurybyAccident $ 500,000 eachaccident I
BodilylnjurybyDisease $ 500,000 policylimit ',
BodilylnjurybyDisease $ 500,000 eachemployee I,
C. Other S�a�es Insurance: COVERAGE REPLAGED BY ENDORSEMENT WC 20 03 O6 A � .
D. This policy includes these endorsemenis and schedules: SEE SCHEDULE
4. The premium for�his policy will be determined by our Manuals of Rules,Classifications,Rates antl Rating plans.
All information required below is subject to verification antl change by audil.
Classifcations Premium Basis Rates
Cotle ��imatetl 7er E1 W Es�imateC
No. Total Mnual a Mnual
ftemunera�ion Remunerotim Premium �
INTRA 137531 '.
. SEE EXT NSION OF INFOR ATION PAGE �
Minimum premium$ 500.00 Total Eslimaled Annual Premium $ 3,503.00 ��.
As indicaled,interim adjustmenis of premium shall be made: Deposit Premium $ 919.00 �.
❑ Annually ❑ Semi Annually � Quartedy ❑ Monthly �
MA Assessment Chg. ���
$3,114.20x 5.5000% $171.00 �
This policy,including all endorsements,is hereby countersigned by (�� """"��--e-efG� 01/22/2008 .
Au�hwizetl SignaWre Oata
GOV �GOV KIND. PLACWG CLAIM NAME SAFETY
STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP Boston Insurance Brokerage Inc
MA 5606 23 505 24 Federal Stree[ 4th Floor
WC 00 00 01.A(11-88) Boston,MA 021]0
Inclutles wpyrigM1tetl matenal of ihe National Council on Compensa�ion Insurence. �
used vnlh i�s Oermission. �
� CITY OF S��I.EILf ti'L-�SS.�CHUSE'1TS
i ,
• BtiII.DL\G DHP 1R'I1�.�i'C
,, ��• 13O W iSHII�IGTON STREET, 3`O FLOOR
� 'P� (97� 745-9595
F.�x(978} 740-9846
��ffiput RY DRISCOLL
I�lrYOR T�iobtAs ST.Pr�RRs
DIRECCOR OF PCBLIC PROPEATY�BL'IIS�TNG CO�L�(TSSIO�iEA
CONSTRUCTION CONTROL DOCUMENT
Pro)eC[�Pitle: Cardiac Maintenance Program North Shore Date:
e ica enter
^
PI'OJCCtLOC�IIOR:—�400 Highland Avenue .Salem MA 01970 Units.#13-#14
� Scope of Project: Interior metal stud partitions
In accordancc with SECTION 116.0-116.4.2 of the 6th edition of the Massachusetts State Building Code:
I � Wilbur Bassett Mass. RegistrationNumber 9699
being a registered professional Engineer/Architect hereby CERTIFY that I have prepazed or dizecUy supervised
the preparaGon of all design plans, computarions and specifications conceming:
[ j EnYve Project ( ] Architectural [ ] Structural ��] Mechanicnl
[ ] Fire Pratection [ ] Electrical [ J Other(specify)
for the above named project and that ro the best of my knowledge,such plans,compuWrions and specifications meet
the applicable provisions of the Massachusetts State Building Code,all acceptable engineering pracrices and all
applicable laws for the proposed project.
Furthennore,I understand and AGREE that I shall perfortn the necessary professional secvices and be present on '
the construction site on a regular and periodic basis to de[eimine that the work is proceeding in accordance with[he i
documents approved by the building permit and shall be responsible for the following as specified in section I
I 16.2.2:
i. Review of shop drawings,samples and other submittals of the contractor as required by the conslruction
contract documents as submitted for the bui(ding pemut,and approval for the confomiance to the design
concept.
2. Review and approval of the yuality connol procedures for alI code-required controlled materials.
3. Be present at intarvals appropriate to the stage of consi:uction to bccome generally familiaz with
the progress and quality of the work and to dcternvne, in general, if the work is being performed in
a manner consistent with the conswction documents.
I shall submit periodical(y, in a form acceptable to the building o�cial,a progress report together with pertinent
comments. Upon completion of the work, I shall submit to the building official a final report az to the
sa[isfactory completion and readiness of the project for .
��P�,ZN 0 'bAss c �
q V( !� .
Signature and Seal of registered professional: � W�LBUR S'G
EDMUND �/' �
o BASSE T
" No. 9 �
� g� I
o �
f � ifi16PIL� _
�`c �' CITY OF SALEM
y� $� G'D�. .
�,;'�s!i � PLIBLIC PROPRERTY
�F '"'��'� DEPARTMENT
._�'I(.�Yi!�� , . '
' '<.1\IiF-Y.I.h.F!'Itll�.l%I.I. � . .
.',I.'`�rq< 1'G�.f'�A5111.\C;ONti-CItLfT � ti.�l.l'�i. �L�tiiACl It q�.�1�iS01')7,�, �
TGI.: '1:9-'�j�)�95 � 1'Ar:978�7�0-`)Ri6 . .
Construction Debris Disposal Affidavit
(rei�uire�l lor all demulitiun and renovatio�i �vurk)
In accordance with the sixth edition of the State Building Code, 780 CMR scction I11.5 -- �
DeUris, and the provisions of MGL c 4U, 5 54; � . �'
[3uilding Permit # _._. __ __ is issued with the condition diat tlie dcbris re�ultin� from
this work shall be disposed of in a pi-operly licensed waste disposal Pacility as defined by MGL c �
1 l 1, S 150A.
The debris will be transported by:
I�orth Side Carting _ _ .
. ���ame uf ha�d�r) . � . � �
"fhe debris will be disposed of in :
North Side Cartinp_ �
(n:une of'fscility) - - �,
12 Swampscott Road Salem, MA 01970
� �uddress��>f I'scility)
� ---_.__ _ .._
- sig� tm'c of xrni' applican[ �
.�z� ��
�ia��
,i�•i,��;.n:�+���
I —
i
I T � ' �
� , , � I
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