34-026 (4) ., 4U � wealth of Massachusetts3�a Regulations and Standards
APR 2 0 22004 Manufactured Buildings Program -
LABEL REQUEST FORM
.This Section for State Use Only
Date Received h
6V Label Numbers Issued:
Fee Received $ ,W i1 g �8
Check Number I co Date Issued: C Issued by: ! w CL;This Section to be Completed b Manufac er-PLEASE PRINT OR
SECTION 1-MANUFACTURER INFORMATION BBRS\DPS I.D.
Manufacturer Name AVISAMERICA/EXCEL HOMES MC# 027
Street 180 HENRY STREET - PO BOX 420
City/State/Zip A V I S, PA 17721
Manufacturer Telephone Number: Fax Number: (570 759-5009
Manufacturer-Plant Inspector
Third Party Agency P F S TPIA #D 2
Number of Labels 4 Total Amount Attached $ A 00 . c o
Manufacturer's Serial Q LWTE: 1 14 CJ a Manufacturer's Model
Number Designation -T l vC) ST y
SECTION 2-LOCATION OF BUILDING I I
Street r kip I I t'i I
City/State/Zip Fiore-ncc, , MA
SECTION 3-BUILDER/DEALER/CERTIFIED INSTALLER INFORMATION
Builder/Dealer THE HOME S T O R E
Street 73 STATE ROAD - PO BOX 300
City/State/Zip W H A T E L Y MA l p g 3
Certified Installer e-
Licensed Construction License Number:
Supervisor J Ck,me S aGk-f f
Expiration Date:
This form shall be completed by the manufacturer when requesting manufactured buildings labels. All
information shall be clearly indicated. Incomplete forms will be returned to the manufacturer unprocessed.
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\mfgLa belReques t
December 17,2003