The URL can be used to link to this page

32A-263 Commonwealth of Mass . - -:.- - 7 1 . �� , (C) � Board of Building Regulations an • : - • . . fi x Manufactured Buildings Pr Jior-42i112 LABEL REQUEST FO This Section for State Use Only 11.11.11 " . ' 7 ''''''''322' Date Processed /c9. al- I I Label Numbers: Issued by: Al , i--■ Fee Received $ 1 p 0, ot) /2 6.S k J- s Check Number -- - This Safi - Onto be Completed by Manufacturer - PLEASE PRINT OR TYPE SECTION 1- MANUFACTURER INFORMATION BBRS \DPS I.D. # U y ) Manufacturer Name o1,rilb"i) c p RP t . S ' MC # 3o Street 17 3 04o a-C. 14 S f City /State /Zip Yick LLE CT ()4q 2 Telephone Number: T O _26Y 3 f1'j Fax Number: o 3 265 -194 Email f ( o .. ( g fIch, ,Co Manufacturer - Plant Inspector MI L I A F L w O RO N O 1P Third Party Agency R. ARNOLD - A SSOC ATE S TPIA # O Number of Labels 2 Total Amount Attached $ IOoc ©O Manufacturer's Serial 2.5 1 1 a Manufacturer's Model c -r-o r a Number 2 site Designation T nip Sf4T o r \ f SECTION 2 - LOCATION OF BUILDING Street B Apt-01oEL7 STREE City /State /Zip NO pry 14 A m j2 TO 1'.) MA 0 1 O 60 SECTION 3 - BUILDER/DEALER/CERTIFIED INSTALLER INFORMATION Builder / Dealer Street City /State/ Zip Certified Installer Licensed Construction License Number: Supervisor Expiration Date: This form shall be completed by the manufacturer when requesting manufactured building labels. All information shall be clearly indicated. Incomplete forms will be returned to the manufacturer unprocessed. 4 This request shall be forwarded to the BBRS / Dept. of Public Safety 167 Lyman Street/ P.O. Box 1063 Hadley Building - Ground Floor Westboro, MA 01581 Bbrs\ Forms2\ mfgLabelRequest March, 2004