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HomeMy WebLinkAboutBLD-22-006408 T Pu c/L.s/2, . of•Y.gR BUILDING PERMIT APPLICATION E APPLICATION TO CONSTRUCT,REPAIR, RENOVATE, CHANGE THE USE,OCCUPANCY OF, - E C (C IT C OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING. r---- 4 ..6TT.Cn[. Town of Yarmouth Building Department MAY '�""'� `� Tel: 1 146 Route _'8 • llinnouth, MA 02664-1•49`2 508-398-2231 ext. 1261 Fax 508-398-0836 8 I'd, Ndffiee Use Onfyr/ Planning Board Information Assessors Department Information: Permit No.& C Da e Plan Type Map Lot ?A' j Endorsement Date / ljPermit Fee $ E/� (�/(/ Recording Date New � Deposit Rec'd. -,Da e Plan No. 1.4 Property Dimensions: Net Due $ Other Lot area(sf) Frontage(tt) Lot Coverage This Section for Office Use Only Building Permit Number: Date Issued: Signature: 's -iI cl \a-, . Certificate of Occupancy. Building Official Date• is Is not required Section 1 - Site Information 1.1 Property Address: 1.2 Zoning Information: gof- 2g w , y ln #u u 1 tr Zoning District Proposed Use 1.3 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.4 Wage Supply(M.0.t_c.40.S 54) 1.5 Flood Zone information: Commentm Public Private Zone: BFE: Section 2- Property Ownership/Authorized Agent 2.1 Owner of Record: 6(5D/me" 1MLiGt✓ lvAlt Name(print) Mailing Address: ✓- 6 /7-50-- '3)06 3 Signature Telephone Telephone / Email Address: 2.2 Authorized Agent Name(print) Mailing Address: Signature Telephone Fax Email Address: j . Section 3 - Construction Services 3.1 Licensed Constru tion Supervisor Not Applicable ID Z Q 1(i{J_ j /{ i o,S n License Number �j ,,,,Address ( �JV V y (� C c� _,,,, 1 0 4 1 0 1 /AMA 503- Z277 - 9 5 L 2, Expiration Date Sig.° - Telephone Email Address: 7> / 2-5 i , ' . ' - • , Section 6 - Description of Proposed Work(check all applicable) • New Construction ❑ (tor multiple family only) No.of Bedrooms (for multiple family only) No.of Bathrooms • Existing Bldg. ❑ Repair(s) ❑ Alterations ❑ Addition ❑ Accessory Bldg. ❑ Type Demolition Other Specify: Brief Description of Proposed Work: V43- , �W o Ake-J C7Ai( .•?; o� • -Ail � �c�. s pAitvA- Section 7- Use Group and Construction Type Building Use Group(Check as applicapable) Construction Type • A ASSEMBLY ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 1B ❑ B BUSINESS ❑ 2A ❑ E EDUCATIONAL ❑ 2B ❑ F FACTORY ❑ F-1 ❑ F-2 ❑ 2C U H HIGH HAZARD ❑ 3A ❑ I INSTITUTIONAL ❑ I-1 ❑ 1-2 ❑ 1.3 ❑ 3B ❑' M MERCHANTILE ❑ 4 ❑ R RESIDENTIAL ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S STORAGE ❑ S-1 ❑ S-2 i] 5B ❑ - Y U UTILITY ❑ SPECIFY: M MIXED USE ❑ SPECIFY: S SPECIAL USE ❑ SPECIFY: Complete this.section if existing building undergoing.renovations;additions and/or change Iri use., Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34 Proposed Hazard Index 780 CMR 34 Section 8 Building Height and Area • Building Area Existing(ii applicable) Proposed Number of floors or stories include basement levels Floor Area per Floor(sf) Total Area All Floors (sf) Total Height(ft) Section 9 - STRUCTURAL PEER REVIEW (780CMR 110 11) Independent Structural Engineering Structural Peer Review Required Yes No SECTION 10a OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNER'S AGENT qR CONTRACTOR APPLIES FOR BUILDING PERMIT I,vi � Apk3 Z- , as Owner of the subject property, hereby authorize to act on my be Jt,+t�alE-r�attters relative to work authorized by this building permit application. 2 72 - Signature r ate • SECTION 191:1-0VirtsIERTA ORIZED AGENT DECLARATION I, X` , as Owner/Authorized Agent hereby ectare that the statements and information on the forgoing application are true and acurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. • Print Name • Owner/Agent Date Section 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be completed by permit applicant 1.Building a Electrical 3.Plumbing/Gas • 4.Mechanical(HVAC) 5.Fire Protection 6.\\J s> • 7.Total Square Ft.Oar new sms4nes&adations) Check Below ❑ Conservation-Commission Filing (if applicable) ❑ Old Kings Highway&Historical Commission approval (if applicable) • • 3.2 Registered Home Improvement Contractor. . Company Hams Not Applicable ❑ • , Address Registration Number Expiration Date Signature Telephone Section 4-Workers'Compensation Insurance Affidavit(M.G.L c. 152 S 25C(6) Workers Compensation Insurance affidavit 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 Section 5- Professional D- ign and Construction Services-for Buildings and Structures Subject to Construction Control Pu uant to 780 CMR 116(containing more than 35,000 c.f. of enclosed space) Section 5.1 Registered Archi ect Not Applicable ❑ Hama(Registrant): ' Registration Number Address Expiration Date Signature Telephone w Section 5.2 Registered Professional En.' eer(s) Name Area of Responsibility Address Registration Number Signature Teleph• a Expiration Date Hama Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Re." ration Number Signature Telephone Expiration %ate Mama Area of Responsibility Address Registration Number Signature Telephone Expiration Date Section 5.3 General Contractor Not Applicable ❑ Company Hama Person Responsible for Construction Address Signature Telephone • The Commonwealth of Massachusetts _ Department of Industrial Accidents ==A10 1 Con press Street, Suite 100 \ 9:t f= T Boston, MA 02114-2017 :...MO SY,,7 www.mass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly ,--/. ��y Name (Business/Organization/Individual): ,,�'( ��t./ Z ,/ Address: 2 �LO -14 A l 53 t( ii-14 7AA,tv- �M 0(_ 01 L— �City/State/Zip: O 0/ Phone #: S o Yi—,340 Y-6 &y Are you an employer? Check the appropriate box: Type of project (required): 1.❑ I am a employer with employees(full and/or part-time).* — 7. _ New construction 2. I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers'comp. insurance required.] 8. ( Remodeling — 3._I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. — Demolition — 4.❑I am a homeowner and will be hiring contractors to conduct all work on my proe I will 10 _ Building addition pensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors with no employees. — 5._ I am a general contractor and I have hired the sub-contractors listed on the attached sheet 17' Plumbing repairs or additions hese sub-contractors have employees and have workers'comp. insurance.$ 13. oof repairs 6. We are a corporation and its officers have exercised their right of exemption per MGL c. 14•❑Other 152, §1(4),and we have no employees. [No workers'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 nzy employees. Below is the policy and job site information. Insurance Company Name: Policy# or Self-ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure 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 form 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 u cer ' -�- nder the p ins and penalties of perjury that the information provided above is tr e and correct. ,,,---§il;nature: 2 S 22 Date: Phone#: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# 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#: §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 30 1-+" ? c/A 121M,.O ti4i Work Address Is to be disposed of oat the following location: Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. 2 ?v'/ 2Z Signa e o Application .Dat Permit No. Ac DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 05/02/22 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 CONTACT NAME: Schlegel&Schlegel Ins Brokers,Inc. (A/C,NN,Ext): 508-771-8381 (AAic,No): 508-771-0663 34 Main Street E-MAIL West Yarmouth,MA 02673 ADDRESS: schlegelinsurance@gmail.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: ATEGRITY INSURED INSURER B: CARLOS ARIEL SUAREZ INSURER C: 290 WEST MAIN ST APT 311 INSURER D HYANNIS,MA 02601 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 ADDLBUBW POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A 01-C-PK-Q220502525617 05/02/22 05/02/23 PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (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) INSURANCE COVERAGE IS LIMITED TO THE TERMS,CONDITIONS,EXCLUSIONS AND OTHER LIMITATIONS AND ENDORSEMENTS OF THE POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 80 ROUTE 28 WEST YARMOUTH,LLC ACCORDANCE WITH THE POLICY PROVISIONS. 80 MAIN STREET WEST YARMOUTH,MA 02673 AUTHOR! D RE ES NTATIVE 1 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ,--s_ CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDDITHEIn 04/z1/zoi.2— IED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS 1FFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES ,fE 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 poScy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED,subject to the terms and conditions of the policy.certain porkies may require an endorsement.A Statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PROWLER ConnACT Jerold O'Su8Nan Leonard Insurance Agency.Inc ,AOnoIN u.En1.(5081428-6921 I IM,50) (508)420.5406 683 Main Street po'yRE53: IemQl0Onardapency.00rn Suite WSURERISIAFFOR0ING COVERAGE WM/I Ostervilte MA 02655 IRSURERA: Evanston Insurance Company 35378 INSURED elsoRERR:The Commerce Ins.Co. 34754 Carlos Figueroa,GSA Cif Remodeling Inc. .,SURE),c:Associated Ind.Of MA-ARWC 26158 INSURER 0: 20 Captain Noyes Road INSURER E South Yarmouth MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 22-23 Updated Master 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 REOUIREMENT,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.UMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS. ITq TYPE OF INSURANCE DSO MVO POLICY NUMBER IMMSOWYYYI IMMIOEIYYYYI UNITS X COMMERCIAL GENERAL LietLRY EACH OCCURRENCE s 1'000'000 Dmlfll£tO PLOTTED CLANS-NAM OCCUR PREMISES IEermerem.t S 100.00 MEDEXP(Any eft Fenanl S 5'000 A 3AA559242 04/15/2022 04/15/2023 PERS0NAL94,oUt RRIY S 1.009.E GENT AGGREGATE LWIT APPLIES PER: GENERAL AGGREGATE S 2'0'°N ^_POLICY❑JECiEl LOC PR000CTS•COMPIOPAGG S 2'"'M OTHER: AUTOMOBILE LIABILITY i�rOinC SINGLE tin $ ANY AUTO BOOBY INJURY IF..0nnant S 250,000 B A0 UT Y x SCHEDULED �ED RVM277 01/18/2022 01/1812023 BODILY 001080 leer avuwml $500.000 HIRED PROPERTY e DAMAGE S 250,000 AUTOS x AUTOS ONLY ryk., Medical payment 110,000 UMBRELLA UAB OCCUR EACH OCCURRENCE EXCESS LIAR CLAWS-SLAM AGGREGATE DE0 I I RETENTION S S WORKERS COMPENSATION 'MUTE I I ER r AND EMPLOYERS'LIABILITY C ANT PROPRIETORTAHTNERIEXEcuTNE []NIA WCC-500-5018589.2021A 04/30/2021 04/30/2022 E.L EACHACCWENT 3 1.000,000 MGF,5ERry E11R EXCLWEOT cnSa under E1.DISEASE-EAGS 1'IPLOYEE 3 '� 0ESCNIPTrON OF OPERATIDI61NNw EL.DISEASE.PQICY uonr 5 1.000,000 DESCRIPTION OF OPEMTT003'LOCATORS/VEHICLES IACORO tel.A44IMw1 Ramat.scM40M,may IN HUHNM IT mem paw N rpuV.41 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF.NOTICE WILL BE DELIVERED IN Calvary Baptist Church ACCORDANCE WITH THE POLICY PROVISIONS. 25 Lincoln Road AUTHORIZED REPRESENTATIVE Centerville MA 02632 019S/.2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ___L i 5 ad 0 VI i • 4 . ..,../ Illi c--..i , • 2. II 3---(') `� = 3 „..... ...... —........ - ----.1.1171111.7111 ..,..i i.. , :,,,7 CI 41‹.1.1.611.° 1 CA ® „.....s ' \\\\/4 v i. I /o . ,� . �....i P ,e.,......................fti 1 • (�.— V (.A 'I 1 r ! t t raw _ _ , 3r g b U q Aro 5 Al i(2.t_ S ID At(K.e("(, 0,1\AJ , 1 1 I i( *ii cH 6 v\I 1 f 0 I i a -4. • i 4 • 1 . i 4 t S_IS' 6 t4 S r S. ['ai F F- 1- Re PA co,eu,4-eks Re ptko o acil - vr IsNlity Eolizy 11---- 0 00 COO 0 ___,I1 ,°.0• 0,,-, ri'---------- 1 00 1 • i i , , ,.._ ..............-I 0 , - ',. . i - i i . 1 4 . !- I t , , 4 1 0 „ 0 0 ,,,------, 0 i l i! ' „ . t - , 0 E) 0 . . ,....„," --k L 0 I 4.VM Ct 1 ! 0 T 0 i I. rt. C"F -----., • ..-7.,,,O,.- '''''''' ,,,•4. '''''--"•tA,- ',,,'-`"-. ',-.7 '.., Office of Consumer AffaiCr:&S I.;s ine:s''9-7eg:ula't/cn 4,- --,ztt ' ,.., ` ' -4 r -.,-• "',--.;''''i'l 'A.rt. .o4,,,, ,r ,A,'' ' 2,2°. .,„.,,,,,c,-- "4'-.• HOtv7E IMPROVEMENT CONTRA C OR , i'YPE:Corporation , ,,,,,,,,,,„• -, , .•-- ,-.. ,--:4;,,,,e5...,..--- ..z..---",,'"4--; 4 1- *713,',1-7----,F--=''' 8-:zatilon C& 021 F REMODELIN15G3 I7N9 C2 c.„. • . 01/07/2 , ---. sz-..-..„-., • ..: ----:,..2.-',..-':- - - - --'-`, --- -- . 41. ‘ „, - -4„„-,It CARLOS H FIGUEROA ".-- _ - 20 CAPTAIN NOYES RD. A -,-, . n.:.--,,,,„-.-i,:•*,,z*,P4',,,,:-:4,47,,,,, . .,..-t ,, --,z,,x.,rz,-,•-,..-6„-,-:::-----•- •- 4! ..N.40,.,.,:;,:;:tr:,-1•'"-;:--4;:t.,,,,,:,--17.,, ...,z : S. YARMOUTH, MA 02604 ,k:--4,,_-- 44,;,••:,.-.,,,,,t--,.:kt ''.4-'4'",2'''°' C j CR---Q41‘--- :-..\-- -s;:. ---'*'-';'='11-'' , s .,-. _ -- -?---.;.-1.\',ft, ,..4.a„s, ,—"',, -.'".,...„:4...,==-= ,.. 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' r'n'ord of Buir'dmg RegLillatiorls- anti, San:tarcis,,,;,...„....- •,,, -, ,. .., -A, of :.... .';', ....... -, , /‘ -‘:sr. 10 10 7 8 2,--- 223 Expires: 0 . - '- ' ' ' J ,, CARLOS H FIGUEIROA .,.* ., 6-1- , . 20 CAPTAIN NOYES ROAD SOUTH YARMOUTH MA 02664:, , , .., , issioner ....„„.,.. , , ......,,:-, ,,... . vrlei 41'''i:•-';':':'.2.,‘ ;•;W'. et',''.?';',''''''..,!•• :7:- • ' : . •-•-„,,,, . -- - : ,:!.. ' , . .4.".:-?4.0,tiir•- .•;,...!,k.,,,•4,‘?„,':,;„ ,.. -,, - tl.,:i.•'-,'W-'•-ti:'1.•,.-t•5-4;',.!4'. .: .,,„,.:" ;) ;'-'r'9:'''e"!.'.-; ''(-4.. '-':,:'iri.VC,,-;;: ti,:::,,*;,1''', -",, V , . , . . , .