38B-066 (6) 251 SOUTH ST BP-2019-1364
GIS#: COMMONWEALTH OF MASSACHUSETTS
Maw lock:3813-066 CITY OF NORTHAMPTON
Loc-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Cateao": ROOF BUILDING PERMIT
Permit BP-2019-1364
Pro ject# JS-2019-002199
Est.Cost:$4800.00
Fee: S40.0o PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License.,
Use Group RCI ROOFING 074334
Lot Size(so. R.): 9583.20 Owner: PIERCE DARREN
Zoning, URB(100)/ Applicant: RCI ROOFING
AT. 251 SOUTH ST
Applicant Address: Phone. Insurance.
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON:5/30/2019 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP &SHINGLE ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy signature:
FeeType: Date Paid: Amount:
Building 5/3020190:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
(ZWF
Department use only
City of North "i n slaw of P rmic
Building Dep rime
t MAY 2 9 20) urb CUVD iveway Permit i
212 Men rest Sew rlSep is Availability
ROOM 1 0wat rMlel Availability
Northampton, A PnUILDINn INSPF ats Structural Plans
phone 413-587-1240 a ns-
_a
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ,ONE OR TWO FAMILY rDLWELLING
SECTION 1 -SITE INFORMATION V W 7
1.1 Property Address: This section to be completteed by office
Q51 S>l74(sc5'E. Map�i ]fir/ Lot h(oVit
ND,f4tkmf-Fan , MA Zone Overlay District
Elm St.District CSDIsWet
SECTION 2•PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1r Owner of Record:
On-l-Gen PIPYCC aSl Ski.Vn S,+ Aim- Imn+rn /YIA 010(on
Name(Pdrd) Cerant Maid Add
413- .M.-9960
Slop (14AP)Iad Telephone
Signature
2.2 Authorized Anent:
C �n Lunn Sa �t4.r,mn4nn (Y)A OIO'7.�
Name(Pnnl) Currant Meiling Addr u:
441 ,) 3a1 -41�-s
Slgnatum Telephone
SECTION 3•ESTIMATED CONSTRUCTION COSTS
Item Estimated Cast(Dollars)to be Official Use Only
completed by permit applicant
1. Building q (e)Building Permit Fee
UpF
2. Electrical (b)Estimated Total Coat of
Construction from S
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) 4 Check Number
This Section For Official Use Only
Building Permit Num an _ Date
Issued:
Signature: 5-29.2019
Building CommleslonedInspector of Buildings Date
S-HTompson @ rCi roofing .Com
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteratlon]s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs I01 Decks j0 Siding[0] Other lC71
Brief Description of Proposed
Work: SPLA Q Aa c-hpCI
Alteration of existing bedroom_Yes_No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement 'Yes __No
Plans Attached Roll -Sheet
on.If New house and or addition to existing housing, comblete the following:
e. Use of building:One Family Two Family Other
b. Number of rooms in each family unlC_, Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stores?
I. Method of heating? Fireplaces or Woodsloves Number of each
g. Energy Conservation Compliance. Messcheck Energy Compliance form attached?
In. Type of construction
I. Is construction within 1001.of wetlands?_Yes _No. Is construction Within 100 yr. floodplain_Yes_No
J. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? YBs_No.
I. Septic Tank_ City Sewer_ Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Do r(en PI PrrO ,as Owner of the subject
property yn� T "authorized
hereby authorize nC.1 r1MY1
to act on my behalf,in all matters relative to cop authorized by this building permit application.
SPo f1 f}pr V1od .5 - nth- 19
Signature of Owner Date
�fK 11P.LS�P_ _ as a11�{�0riZPl /Ilb/Y} as Owner/Authorized
Agent hereby declare that the statements and information on the fo ping application are True and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
5- a4 -14
Signature of Owner/Agent Data
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 17
Name of License Holds : Mor IAf K III M& C— 40-1 .-1,!�y
License Number
59
I n-Mn mrd Ol(3a7 05 - 03- aoao
Adores. r Expiration Date
14131 .5a7-4�`15
Signature Telepimne
9.Registered Home:Improvement Contractor: Not Applicable ❑
Pi C= AoOF nG LLP /d(0435
Company Name L, Registration Number
(o LIn2 S+ Snr4�Tn vrNein YYIA (71013
10S - 05 - aoao
address��—' Expiredon Date
Telephone 41.3-Sd74715
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.O.L.e.163,$25C(6))
Workers Compensation Insurance afndavit must be completed and submitted with this application.Failure to provide this affidavit will result
In the denial of the Issuance of the building permit.
Signed Affidavit Attached Yes....... &( No...... ❑
City of Northampton _
MassachusettsDErp"
mr
2122 MENTMain
or BUILDING al bSCTzpg3
IIr Main .thee[ • Municipal 02l aui141nq
Nortl�a�tnn, 14l OlafiO
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes.Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstmctlon, alteration, renovation,repair, modernization, conversion,
improvement,removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than Pour dwelling units....or to structures which are adjacent to such residence or building'be
done by reigistered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered
Type of Work: Est.Cost: ` yl 800
AddremofWork: Q5� N ampjz (YIP 0101 )(L
Date of Permit Application: A– a4 –at1t9
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
—Job under$1,000.00
_Owner obtaining own permit(explain):
Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
R .C.I o� �� LLP ia(0135
Date Contractor Nam HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
a
Massachusetts DBPMB NT OF BUILDING INSPECTIONS
212 Nein St—tMunicipal Building (i)
NB 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
a51 /un,-4k)nmFr1nn
(Please print house number ands et name)
Is to be disposed of at:
1A)P5.4Dr-n A4r_Imn Tancfpr
(Please pnn ame d location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
�)�p Nniilinn Coil ,Qerf�lfnn
(Company Na a and Adtlress)
Signature of Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
' LN The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 0211 4-2 01 7
www.massgov/dia
Tworkers'Comphingstlost Insurance Affidavit:Builders/ContracturL'Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Name(Business/Organimdon/Individu l): PAC'. UJ> 0O J.-LP
Address: (D Ll np. 3+roa+
City/StateiZip: jJ1093 Phone#: 5;)7- f)5
Are yet m employer?Meekme.pprophate box: Type of project(required):
I.�l am a employer withlI
.15 ralsyem(fullmd/mpantimi 7. ❑New construction
2❑1am a sole pmprietworpumenhlpmdbevememplaym working fmmcin g. ❑Remodeling
mycapanity.[Noworker'comp.maumnn intuited.] 9. ❑Demolition
3.❑1 am a M1omwwnet doing all woh myelf,poo worker'tamp.insunnu rquimdl a
4.❑1...homeowner and will be hiring coma mors to conduct all work on my protests. twill 10❑Building addition
m that ellcmtncton ulha have work<n'competuenon insurene ware sole I1.❑Electrical repairs or additions
pmpdeto s with no employees. 12.❑Plumbing repairs or additions
5(2 Lm.general contracmr End have hired Ne sub-imetramon listed..thean ched ehttt. I3i00f repairs
Tlsesc aub-embectera have employees and have workvi .comp.insuri p
6.❑We ase.eorparmon and its omccn have cxetciacd their right of aempdm pm MGL c. 14.❑Other
152,51(4),andwe have w employee.(No worker'comp.irmumn«regovedl
•Any applicant Mat rMedp box al most also fill out the section below showing theirworker'compensation policy infwmntion.
t Homeowners who mbmit this affidavit indicating they me doing ail work and Men hire outside contractor most submit a new a fidavit indireting such.
IContrZin.that check this box must attached an additional sheet showing the name of the sub-contractor and suite whether or not those entities have
employees. If the su-emare ton have employees,they most provide their workers'comp.policy number.
/am an employer that is providing workers'emnpensation insurance far my employees. Below is the policy and job site
information. n
Insurance Company Name: I m l 1,151i1=10 LD
Policy Nor Self-ins.Lic.#: VWC I ()Olan lt,,V a618A Expiration Date: /U- OS-d019
lob Site Address: aril &xh, S+ City/stale/zip: p 616(00
Attach a copy of the worker'compensation policy declaration page(showing the policy number and ex Ifotion
Failure to seems 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 farm 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.
I do hereby certify under the pates d penalties ofperjurythatthe infornmdon provided above is true and correct.
Signal= Date' 5 ' '14'x019
Phonell, LUl3) 6D,- 4g95
Official use only. Do not write In this area,to be completed by city or town official
City or Town: PermitUcense#
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#:
RC.I. Roofing Estimate °ate
6 Line St.
Southampton,Ma.01073 5/9Y1019
Phone(413)527-4775
Fax(413)527.8469
Name/Address Job Location
Darren Pierce
251 South Street
Northampton,MA 01060
Terms Rep
Estimate valid for 45 days Chris
Description Total
Remove existing roof. 4,900.00
Fumish and install 1/2'fiberboard insulation,mechanically fastened.
Furnish and install ,060 reinforced rubber roof system.
Furnish and install all related flashings.
Furnish and install .032 aluminum drip edge.
All exterior roofing related debris to be removed by R.C.I.Roofing.
All work to be performed according to manufacturers'specifications.
5 year R.C.I.workmanship warranty included.
All related permits will be obtained by R.C.I.Roofing.
WE LOOK FORWARD TO DOING BUSINESS WITH YOU.
Total a4,soo.00
TERMS OF PAYMENT
5%Deposit Customer Signature: wc""C_ „• p
Balance upon completion
Registration M 126235 S aZ
Date:
Canstruction License#074334 /�
Insured by Banns&Ficker,Ins, Shingle Color Selection: 4'00f/P R05l05 flv&
(413)527-2700
A M CERTIFICATE OF LIABILITY INSURANCE o'"s a1D9 1
THIS CERTIFICATE IS ISSUED AS A MUTTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.TRIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE GOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the Certificate hold.,Isen ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or M endorsed.
If SUBROGATION IS WANED,su0laet to the terms and conditions of the policy,certain pollcNe may require an%Itl%semsm. A afstsmsnl en
Nle certlflcate does Not confer rights to the car00cate holder In lieu of such endorsement(s).
PRODUCERNN Michael R.Banas E:
Banee S Fickert PE
S . 113-51]-1]00 /7%17-09!9
Insurance Agency A�UREss: m0�ranasllauranca.com
63 Main Street
Easthampton,MA 01017 INSUREP4SIAWOMMLOVENWE :•
INSURERR: Admiral lnsumnCe Co. 11966
lmum INSURER s: Safety Insurance CO. 3UP
RCI IFFUR g,Lt➢ DIVIDEND: Admiral Insurance Co. 21656
6 Line Street INSURER D'
Southampton,MA 01073
%waeR e:
INFORMED F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFYTHATTHE POLICIES OF INSURANCE LISTED BELOW NUM E BEEN L%UEOTO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD
INDICATED. NOTV6INSTMUNOANY REQUIREMENT,TERM OR CONDITION OFANY CONTRACT OR OTHER DOCIIMENTVATH RESPECTTO NMICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCEAFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECTTOALLTHE TERMS,
EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY MID CLAIMS.
INM
LTR M.OFIN uM = lmso POLICY NUMBER MMgDM'YY MWD Hurts
X WMMERCMLOENFIULUMMTY EACHMCURRENCE 1 1,000,000
CLVAS#NL£ ❑X OCCUR PREMIRSIFIDDPENI a 60,0100
MEDW f 6,000
A X CA000010863-05 02101/19 O3JON20 reRsaN.usAwnulHm f 1,000,000
OEHLADGEGTE WITIPHEa PfI! MNEMAOpRen f 1,000,000
P0.ILYO JER LOC PRODUCTS-cowI )PAOO f 1,01gli
O HER'. f
IF
ADMYOYLELWWIY Er ardXenl f 1,000,000
ANYAIRO BODNYINJURYIPFrpRFm1 a
B Oe.XEDaar X SCREDUED X 6107761 OW30MB 09/30M9 BDURYIwURIffsrepeXMXI 1
Mlrpe Mhos
X TIMED X xgxoMNFn f
.WTOa p4Y IF.xx
f
WBRfLLA Wa OCCW EACH OCCURRENCE a 6,000,000
C ncpet CLANwNUvE X GX000000366-03 0~9 03/01/10 AGGREGATE f 5,000,000
DED X REIFMMNI 10,000 a
Yms oepaeweAnox
AND EMPLOYERS ILVIILITY YIN T E
ANYPRO
OFFICEPARMTNRLNUMEDiECUTNi NIA EL EACH ACCIDENT It
pFheFrrkNN
oYNHEAS
I ELDISE-EAEMPL f
OEStIM 11pr1 pFOPFIUTIMStMw EL DISEASE-POLICY LIMrt I.
DESCMPnOXOFOPEM 3ILOLAn IWMICIls 1A00Rp 1%.AaIXmY Ro,MMF&MW,myMNSMeHmen rpkFM,pWM)
ROOFING CONTRACTOR.
CERTIFICATE HOLDER CANCELLATION
SHOULCANY OF THE
VE DESCRIBED
ACCORDANCETHE WITATHEOPOLOF,NOTICE WILL ESBEVERED IN BEFORE
COPY A CDNWPM ME POLICY
NOVISIONS.BE DELIVERED IN
I5 ACOIFDCORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered mart of ACORD
4fid CERTIFICATE OF LIABILITY INSURANCE p'pYi9m^I
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, UTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTRIITE A CONTRACT BETWEEN THE ISSUING INSURERISL AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: H the urtl0cate holder is an ADDITIONAL INSURED,the policy(Me)must W endorsed. H SUBROGATION IS WAIVED,sublam to
Iter terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the
certi6caw holder in lieu of such endorsement a.
veopuceR mAmzMichael Banas
BANAS&FICKERT INSURANCE AGENCY °NOME 413 527.2700
ruL eWwmnce.ram -
63MAIN ST MFplmxpLgyBMpE NJCF
EASTHAMPTON MA 01021 aNIIIIAA: AIM MUTUAL INS CO 33758
sompe M a.
RCI ROOFING LLP wu
xlawxp:
6 UNE STREET
SOUTHAMPTON MA 01073 F:
COVERAGES CERTIFICATE NUMBER: 3TBSM REVISION NUMBER:
TMS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE poi FBI
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR COMMON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE 199"OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN M SUBIECT TO ALL THE TERMS,
E USIONS AND CONDRIONSOF SUCH POLICIES.UNITS SHOWN MAYHAVE BEEN REDUCED BY PAD CWMS
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a
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A mtmamLEsaLomv ® MM ISA VWC10ONR2 M=I" 1Q0512010 1W05rt019 EL FKH ACLTBR 1000,000
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OEECIIIpsor.Treets' ..'YEexlEe(Amaplat.AtlWnY RenRp aWYM,myM manualf—'M:4Mt
Workers Compensation terrorist Will be paid to MaaeaCtmeem employees oMy.Pursuant to Endorsement WC 2D 03 06 B,no Budtoriraton is elven to mY
Col.for benefits to employees In antes other Than Massachusetts if the Insured hires,or has hired those employees outside of Massachusetts.
This certificate of insurance slows the pds,r In force on Ne date that this cerbf N Was Issued(unless the esplutlon dale on this above policy precedes the
issu data of Inds cedificete cf imumnce). TM status of Nis coverage cart be monitored daily by accessing Ne Proof d C eB -Coverage Verrl dw
Seardl tool at Www.mass.gpvdedboMersmmpenaetbMnvestlgatlonM.
CERTIFICATE HOLDER CANCELLATION
0p SHOULD ANY OF THE ADESCRIBEDPOLI S CANCELLED BEFORE
THE SuPIATE THEREOF. NOTICE WIM BE DELIVERED 1.
Reference Copy ACCORDANCE WRH THE PDGCY PROVISIONS.
Reference Copy aUTNm1®1RAeNMATm
—D .tpf
Reference Cagy Daniel M.Crcr ey,CPCU.Vice PrpMeM-ReaNual Market-WCRIBMA
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 2512014M) The ACORD name and logo are registered marks OF ACORD
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-
HOME IMPROVEMENT CONTRACTOR ,
TYP :Penners Expiration
,
05/05/2020
RCI ROOFING, 1 r ( � -• _
t
n Commonwealth of Massachuselll '
V
MARK T.DELISL , l�l Division of Professional Licensure
1 \ �� -�+-p—
BUNE ST J � Board of BUIItlInO Regulations and 6lentlertls
SOUTHAMPTON,M 049T0 Undersecretary Consk!#t1i4N1tpyjfVleor
_ . CS•074334 ,B'< , akylres:05I03/2020
Registration valid for Individual use only MARK THONIg8
before the expiration date. If found return to: So BRIGGS BF EEf 2.'
Office of Consumer Affairs and Business Regulation
EASTHAM
PTON%MA•+0 , D�'
1000 Washington Street•Bulla 710 Boston,MIA 02118
Commissioner
Ii
Not valid without signature
'OMMONW L•T.M'0WaK1SRS,9bIt,,`
HOME IMP �s ONTRACTOR ° e e • eSHEET
tr i.N� IsBU FQWQtNING f JS'E v..
01073 R•UN FTED ✓3'`
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