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BLD-23-005803
ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department 1146 Route 28, South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 1 < •C. Massachusetts State Building Code,780 CMR ,. `e Building Permit Application To Construct, Repair, Renovate Or Demolish , .�M a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: -- 3 Date Applie ' `),Ats -1.,;���) �M Building Official(Print Name) gnature Date SECTION 1:SITE INFORMATION �+ V D 1.1 Pro er�j A dress: ( �,,/ 1.2 Assessors Map&Parcel Numbers — E �e 1C,..I.t ►�}V s1 6. 7"" EAPR 1.1 a Is this an accepted street?yes no ay9 Map Number Parcel Numbe 18 2Q23 1.3 Zoning Information: 02 (f 1.4 Property Dimensions: (( BUILDING DEPARTMENT Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) I 8y. — _ 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required I Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: Outside Flood Zone? _ Public 0 Private 0 Check if yes❑ Municipal 0 On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: r(q w 0(41A, �, (J Name(Print) ,� ` U City,State, IP 0- 7 12VfW2— Ca I 7 7 51.c-31071:2 wit 6 2,3,-, 4e- rInCii refik_,__ No.and Street Telephone ,mail Ad less SECTION 3:DESCRIPTI OF PROPOSED WORK2(check all that apply) New Construction❑ I Existing Building❑ Owner-Occupied ❑ [ Repairs(s) ❑ Alteration(s) A Addition 0 Demolition ❑ Accessory Bldg. ❑ Number of Units Other 0 Specify:tlifL ; i?0 Pte.l ��, ' L Brie De cript of PropotWsrk2: i C g} ' ''fit yrs t 'p Oi r\S U / ECTION 4: ESTIMATED CONSTRUCTION COSTS. • Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ Q')� 1. 9 Building Permit Fee:S1 Indicate how fee is determined: 2.Electrical $ l�� ``'� IDStandard City/Town Application Fee 0 Total Project Cost (Item 6)x multiplier x 3.Plumbing $ Lf () U v 2. Other Fees: $ 4.Mechanical (HVAC) $ List: l-4 13LJ 5.Mechanical (Fire $ `� . Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 1\ 0 Paid in Full 0 Outstanding Balance Due: 0 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Superv'sor License(CSL) >j // c\t tj SDI-e..1 l License Number.( Expiration Dat Name of CSL Holder ' \ 3C^ i)aki/„J l4G)1 ' 1/,) List CSL Type(see below) U No.and Street �[ \(/J� Type Description 1014V( /,Ate, 61 /- OTeb U I Unrestricted(Buildings up to 35,000 Cu.ft.) City t U e d(J own,State,ZIP R Restricted l&2 Family Dwelling 1v1 Masonry RC f Roofing Covering WS Window and Siding ���^��� � G � 'Ts � SF Solid Fuel Burning Appliances ,t4� Q I l u kpvh p Insulation f elephone Email address U D Demolition 5? Registered Home Improvement ontractor(HIC) 6 j HI-Registration Number Expiration to C Comp :y i'am r egistrant_ e -�r� �r1 (� I1D h5p�/Ln tfS �-1 thiktpCi, a. �d treet Vela/ rt �/ l^E (o 3 31 3 r Email address City/Town, ate,ZIP ,J Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) Workers Compensation Insurance affidavit must be co g'.leted and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuanc- .f the building permit. Signed Affidavit Attached? Yes P No 0 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWICER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize_ to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) ___0„... (on au_ a 41 �Cr'ate • SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains an penalties of perjury that all of the information contained in this application is true and accurate to the bes my owledge and anding. �� �h7 Print Owner's or Authorized Agent's ame(Elections azure) Date NOTES: 1. An Owner who obtains a building p it to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at www.mass.cov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halfibaths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" n� be hs perm, J-s L ighP §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-223[1 ext. 1261 Fax 508-398-0836 Office of the Building Commissioner BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Ch. 40, §54 and 780 CMR- Section 105.3.1. #4. I hereby certify that the debris resulting from the proposed work/demolition to be conducted at � V?4'4-et jL rr VW'\ 6a-(9,c Lf Work Address Is to be disposed of oat the following location: hb Ctt cV Said disposal site shall be a licensed solid waste faczlity askinved-ty Ch. 111, §150A. Si4(//,7/ ture of App lication Date Permit No. MA HIC#187510 Page 4 of 18 Long Roofing, LLC • 300 Myles Standish Blvd Taunton MA; 02780 LONGHOIVIE: (800)470-LONG • (240)473-1400 • LongRoofing.com PRODUCTS By Long Roofing, LLC Terry Williams 6175153829 Date:04/04/2023 28 Rita Ave terryb323@gmail.com Product Specialist: Scott Duquette S Yarmouth MA 02664 The Buyer(s) listed above hereby jointly and severally agree to purchase the goods and/or services listed herein, in accordance with the prices and terms described in this "Agreement." Homeowner's Association Approval Required NO I do not belong to an HOA. I accept FULL responsibility for this project and authorize installation I confirm that the above information is accurate Dumpster Required NO I confirm that the above information is accurate Are there electric lines within 3 feet of where LHP will be performing work? NO Preferred Method of Contact Phone Phone/Text/Email 617-515-3829 Total Purchase Price $11,800 Deposit with Order $4,000 Amount Due on Substantial Completion $7,800 Amount Financed $0 Form of Deposit Check The Estimated Date of Commencement of the Work Is 3-5 Weeks The Estimated Completion Date Is 3-5 Weeks I am aware that the above dates are an ESTIMATE The Project Is Contingent Upon Obtaining Permits THERE ARE NO ORAL AGREEMENTS Promotion Selected(Cannot be combined with other offers) Cash Discount Customer Promotion Acknowledgment This space intentionally left blank It is agreed and understood by and between the parties that this Agreement, constitutes the entire understanding bd of 18 the parties, and there are no verbal understandings, changing or modifying any of the terms of this Agreement. Buyer(s) hereby acknowledge that Buyer(s) has read Agreement and has received a completed, signed and dated copy of this Agreement, including the two accompanying Notice of Cancellation forms, on the date first written above. Buyer(s) acknowledge that they were orally informed of their right to cancel this transaction. Scott Duquette Terry Williams 04/04/2023 04/04/2023 Date Date You,the buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.See the accompanying notice of cancellation form for an explanation of this right. This space intentionally left blank leaptodigital.c:om 2.14.4 , • • • • • • '' yo nm'oriweaith•o{ rf ss c `use'i ' ' Division-of Rrofessibnfii•'Llcenstgre . • r Board-of BUilefin j.Re"gulatiorig,and:Sfandards,, • • eons r '" t .ISdr CS-• ' v5 0<L`, • ' i'; � i Tres .p �2129/2�2�. 8 PAR33F' R RD - xs" ;x {z: EASX B s = ;: � 'C " �• •a ':y:'• !': �L .F,.gip.•� C`�,y n,. c .�,._ ' i n7f. l011Qr �'"':e:•._ '-•:.,..,-,•.;_sue.^ THE COMMONWEALTH OF MASSALHUSL I I S Office of Consumer Affairs and Business Regulation 1000 Washingtorq.S_eet- Suite 710 Boston-Massa:chusetfs 0:2118 Home Improvement Contractor Registration a� , i I I 1 L.6''r I ���I II�'"'Ijl Ire 'r;'.� h� � Ili ll,l Type: Supplement Card gall I, ,_,il I, ___ aeg'istration: 187510 LONG ROOFING LLC If all 1 it -- =v Expiration: 04/20/2023 D/B/A LONG HOME PRODUCTS ..it r"'�-=T I ,I 8530 CORRIDOR RD, SUITE 200 -1, '11 ra - MI I ''u',�''' SAVAGE MD 20763 tiI 'til, 1 ' I.* iI ;:=- .£'Nye 1y1' --1 'i �",�' +, "a i _ Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affai'rs,&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT,CONTRACTOR expiration date. If found return to: TYPtE._5upplement_Card Office Consumer Affairs and Business Regulation Registration '^., Expiration 1000 a hington Street -Suite 710 1187510 11r.1 04/20I2023 Bos on, A 02118 _ONG ROOFING LLO,e)Ij `)I� I'rll i i i� )/B/A LONG HOME PRO,DUC�TS�'` ', 4 I, III G , ,+ i ,I TAMES COSTELLO I4 . -I_ I I530 CORRIDOR RD,SUITE 2d0 ' „(,,,,„,,„da'( % / _ SUITE - UndersecretaryNot valid without signature 3AVAGE,MD 20763 _. The Commonwealth of Massachusetts • Department of Industrial Accidents P.1 •'- 9 Office of Investigations 1<\ Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 + yi • www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Long Home Products: Long Roofing LLC/Long Baths LLC Address:300 Myles Stanidsh Blvd City/State/Zip:Taunton MA 02780 Phone#:339-333-6118 Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with 25 4. I I I am a general contractor and I employees (full and/or part-time).* have hired the sub contractors 6. I I New construction listed on the attached sheet. 7. ®I Remodeling 2.ID I am a sole proprietor or partner- ship and have no employees These sub contractors have g. Demolition working for me in any capacity. employees and have workers' 9 E Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ILI We are a corporation and its 10.11 Electrical repairs or additions 3.U I am a homeowner doing all work officers have exercised their 11.n Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.1 I Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.n Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Liberty Mutual Insurance Company Policy#or Self-ins. Lic. #:WC5-31 S-626143-013 Expiration Date:1/1/24 Job Site Address: s City/State/Zip: the workers compensation policydeclaration page(showingthe policynumber nd expiration date). Attach a copy of p p Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and the p s and penalties of perjuaat-- ' or rovided above is tr e and correct. Si. ature: / Date: Phone#: 3,.'' 6118 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (check one): IOBoard of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.1:1Other Contact Person! Phone#: DATE(MM/DD/YYYY) A�O® CERTIFICATE OF LIABILITY INSURANCE 1/8/2023 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, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER ALLIANT INSURANCE SERVICES INC NAMEACT 16901 MELFORD BLVD STE 123 PHONE - — - FAX BOWIE, MD 20715 E ANo Ex -IL I (A/C,No): ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: LM Insurance Corporation 33600 INSURED INSURER B: LONG ROOFING LLC DBA LONG HOME PRODUCTS INSURER C: LONG BATHS LLC INSURER D: 8530 CORRIDOR RD INSURER E: SAVAGE MD 20763 INSURER F: COVERAGES CERTIFICATE NUMBER: 72387605 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. — — INSR '.ADDL,SUBR ' POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER �(MMIDDIYYYY) (MMIDD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED l CLAIMS-MADE -j OCCUR PREMISES(Ea occurrence) $ -_ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY r—I JECT i l LOC PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED i— SCHEDULED BODILY INJURY(Per accident) $ _ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY - AUTOS ONLY (Per accident) $ 0 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ I I $ A WORKERS COMPENSATION I ', WC5-31S-626143-013 1/1/2023 '1/1/2024 I �/ PER H STATUTE ER AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1000000 OFFICER/MEMBER EXCLUDED? Y N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1000000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1000000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) WORKERS COMPENSATION INSURANCE COVERAGE APPLIES ONLY TO THE WORKERS COMPENSATION LAWS OF THE STATE OF MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE _Jon Smith ! .� ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 72387605 1 1-626143 1 23-24 WC- I n0270258 11/8/2023 5:11:08 PM (PST) I Page 1 of 1 LONGFEN-04 DHARRIS ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDmYv) 1/3/2023 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, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). _ PRODUCER License#0C36861 CONTACT Danielle Harris NAME: Lanham-Alliant Ins Svc Inc PHONE FAX 16901 Melford Blvd Ste 123 (A/c,No,Ext): (A/C,No): Bowie,MD 20715 AD?REss,danielle.harris@alliant.com INSURER(S)AFFORDING COVERAGE _ NAIC# INSURER A:Everest Indemnity Insurance Company 10851 INSURED INSURER B:Commerce Insurance Company _ 34754 Long Roofing LLC dba Long Home Products INSURER C:Burlington Insurance Company _ 23620 300 Myles Standish Boulvard INSURERD: Taunton,MA 02780 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMBS _ LTR INSD WVD IMM/DD/YYYYI (MM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR CF4GL01198-221 12/31/2022 12/31/2023 DAMAGETORENTED 100,000 PREMISES(Ea occurrence) $ 1 MED EXP(Any one person) $ PERSONAL&ADV INJURY $ 1,000,000 GENt AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X JECOT- LOC PRODUCTS-COMP/OP AGO $ 2,000,000 OTHER: EBL AGGREGATE $ 2,000,000 B AUTOMOBILE LIABILITY �(Ea accciden SINGLE LIMIT $ 1,000,000 ANY AUTO BCDX02 12/31/2022 12/31/2023 BODILYINJURY(Perperson) $ OWNED SCHEDULED AUTOS ONLY X AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED I PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ C UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 X EXCESS LIAB CLAIMS-MADE 600BE00525-03 12/31/2022 12/31/2023 AGGREGATE $ DED RETENTION$ Aggregate $ 5,000,000 WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YI N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth AUTHORIZED REPRESENTATIVE bikkile fie- gtat:6 ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and loge are registered marks of ACORD RF"IEW' 'i, ;r C0,1PLI- -'-).A At E THE . `� :,-, ' A. _.,. . ... - ...BUILT" CCU... .. _. DATE: `k'1%1-'13 BUI I G OFFICIAL \ . ::,...-1- ti \.. a - - A ± iji !L,tIITT1iI