29 VALLEY ST - BUILDING INSPECTION (2) n
The Commonwealth of Massachusetts
CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 C RECEIVED
SD VICE
- dMar20ii
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling OCT _
This Section For Official Use Only
BFBuilding
ilding Permit Number: Date Appl'
Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
Property Addre. ,- 1.2 Assessors Map& Parcel Numbers
.21
yaYCpv
L la Is this an accepted reet?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Propose Use Lot Area(sq ft) Frontage(Il)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required 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:
Public❑ Private❑ Zone: _ Outside Flood Lone?
Check ifves❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: 1�"
Lea(—Swoa ' cUn 0, 54.1�em, rnA Q l q 76
Name(PIR City.State.ZIP
2Q 97$S'3 5�
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
r"nupw t
s
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building $ 69U, 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ l 2. Other Fees: $
4. Mechanical (HVAC) $ List: Z)
5. Mechanical (Fire
Suppression) $ Total All Fees: $
r' y Check No. Check Amount: Cash Amount: _
6. Total Project Cost: S blo t)I 11 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Number
f 87 License Number L'xpiration ate
Name of CSI, Holder
12
List CSL Type(sec below)
—tu���rs '�•
No.and Street Type Description
U Unrestricted(Buildings up to 35.000 Co. ft.)
R Restricted 1&2 Family Dwelling
Cihl1'own, Sta(e.ZIP M Mason
ry
RC do Covering Win
� WS Window andndSiding
SF Solid Fuel Burning Appliances
q7$- 5-3P I 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) (4860
3:,
to t816
1,;06 V660- cex)��- _ HIC Registration Number Expiration Date
HIC Company Namejgr HICi�cfistrant Name
t7! r-CL 64vie. 6weJ.6 m
No.and St ce{
— St
lYti(1 17�7 Za — 11.7-351-09LA En it ad ress
City/Town,/Town,State, P � Telephone &44
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 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 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES��F(OR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize (,6n4 U/�—
to act on my behalf, in all matters relative to work authorized by this building pennit application.
JD rScLV)Ca
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNERS OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the infonnation
contained in this appp�pliccaatiiIon is true and accurate to the best of my knowledge and understanding.
lI,�
Print Owners or Authorized Agent's Name(Electronic Signature) f ate _
NOTES:
I. An Owner who obtains a building permit 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. 142A. Other important information on the HIC Program can be found at
m ww.mass.uov/oca Information on the Construction Supervisor License can be found at www.nriss.,ov/dns
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 half/baths
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"
-_� I tic l..i!/t1tt161111Velfrit/ f/I ;17 t1.1517 Ct/ll.len.\
L
F—> Deparhnent of Industrial Accidellis
D%ftee of ltivesti,atio'tis
rr=,,e 1 Con-ress Street, Stdlre 100
O
y f 7 Boslott, MA 02114-2017
wwrv.tnass.gol'Idin
Workers' Compensation Insurance Affidavit: Builders/Co11tractttrs/Electricians/Plu it]bers
Aimlicant Information i Please Print Le>?ibh'
N 81111. (6uciness'Chgani�atiort9ndi titlu�lj:—,._�� q��
A Clel l'eSS: __�a 11�C3K.1 , t✓�. _ j
CirylStatclZilz �{er��j� (�� p196D Phoney:
Are vnu an employer." C:hccl: the appropri ate box: —�
qpe of proiect (required):
I. I am a enmloyer «Ith I- -- i. ❑ I ant r 'eneral coil rac( rand I
IIIpJ >y-Ces (ful) andurpart-bane).* have hued the uh contia:l'n; b. ❑ :Nutt cunzlruruon
2.❑ I it))) a sole pro a iclol ol 'm miler- listed on the :tit aehCd sheet.I I I 1- ❑ Itunocialing
hip and have no c mpltit:es `('hex Nave' ti, ❑ Demolition
working for "le in any capacity, amplovices and have m+'Jrkcrs'
[No workers' conjp insurance coin,I I o ❑ 13u m,lldl addition
usurancea
cquired.1 5. ❑ We tic a corporation and iie 0-❑ Llcur i_al rcl,r,rs of additions
).❑ I am a homeowner doing all work officers have exercised ohcir 11.0 Plumbing repairs of eddhione
imself fNo tvorkers' comp. right ol'exempuon per PitGI_
insurance required] .i
C. 151 §INK and we h,we no I?_-❑ Roof repairs
1
employees. f No vvorkert' .❑ (hhcr
comp. insurance icyuireld.]
"Any-q pl-rim Thal Check., bus _i nuia also hll uul the:CClioir bclmv shut,ing thcii % , kei5'ct>mpm,9arim,polity in It,nrrnI ion.
I-Inn o r,grit ubmit dds 'ca'n a i'dimiag Ihey an dun,M,dl Ma ork am dren ant ownidU unHr u'lors unrvt cuhtnir s n:o ;d�iJ;n-ii a dr i,iue such.
phi••b,.0 uu�er.nl:rchtd ao atlduian,al sheet shutving rite uarnr a the WI "aeMM mnl•r.nc"son or ram Ownold"No.:
cn,plu,cc;- It[tic,adh-c^mra¢iors' hate euq,lo,'erS.they"'till pioeide d,eir uozkcis comp,jwiiev numhcr.
i
/ani an cinlihlrer that is protdding workers' conipens'atian insurance fin.filP enipht reec. Retail.is the politic and joh she
igla/'Inali,ni.
Insurance Company Name AmCr,4An .. �II4
p
Policy Cy or Self ins L.ic. ,
---u-9 7 J V,_05 4 -V�._� 13 I `-�-91
_ _ . �._ t x"ration Date: G
I -
lob tint Address -. -- 7Q— � • C ns;Ctatc'Lip:_ itzyn (It(} 61170
Attach .a copy tit'the 'ror hers' compensation poli V declaration pane shot,Wg t- -
1 I, the parley uumbu and esl,u anon date?.
Pailulc to "oewt coverage IS required under Section 25A of MGL c 152 carp lead to dae imposhmn of cl i ndaw penalliea of a
title up to SI.500 (10 andiol one-year impnsonnwnt as well as civil pcuallie. in the Ibrn, of a S 1"0I' WORK ORDIiR and a fine
of up to $2501M a day ag aural the vial nor. Read vised that a copy of this statement nun; he turvardt!d to the Olnice of
Invcnuguunsof the DIA lot insurancc coverage verification.
I da hereby cerli the iahis anti! penalties of ter?a:p that the infin-niWhitt provided abore h true and current.
O ficiill use onlr. I)a not write in this area, it) he coulple'ted hr ci(v or to ion afJieial _
City or Tbtrtl: _ I'crmit/L,icedsr ?r
Issuing Authority (circle role): — ---- ---
I. Board (it' 2. Building Department 3. Cityl own Clerk d. F ecrrical Inspector' 5. 1'lumbin;; Inspector
6. Other
Contact 1'crso°' We #:
Y- Offitt,)(C'nn.umer Affairs A.fluninex5 Rc;;ulatinn L.irense urregistration valid for individui use nnlp
`} ="HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return In:
^.:CEf�'*
µr` Registration: 148688 Type Office'If Consumer:hfhtirs and Rosiness lLr��ulation
Expiration: r 10 Park Plazn•Suite SI',0
P 10118.2015 Supplement- aid 110slon—NIA02116
LCWE'S HOMES CENTERS INC
RICRARO TURNPIKE
RD,S Not valid
O TURNPIKE RC.SUITE 100
SCUTii6C^HOUGH. NIA 01772
Imdrrxrretan' without signatu rr
f i
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Ift Massachusetts - Department oil Public Satety
Board of Building Regulations and Standard~
('„n.truai ,n Wperu. r Wl$
License: CS-071187 , '.
RONALD E W ACFKUN "
12 TUCKERS CT,3RD FIL
PEABODY MA 61960 r- '
I
J� `xp,ration
r_pmmisvoner 0810412015
i
i
("ubsr of t unxu wel Affxirs S IluRuietis Hcguhhnn Llttuc4 of rr>•ItU'ntion valid for indtvidul use only
before file ex1 frstion date. If tonnd rclurn to:
OME IMPROVEMENT CONTRACTOR
agistratlon: 113414 Type: Office iScouslinner Afhurs and 0usiness Regulation
k 10 Pnrk PNza -$uilc 5170
1)
x Iratlom. 6127/2015
P Bnston;DIA0ZI16
RO r O CONSTRUCTION,
RONALD V!AC'HLIi•I
RsEAL X)Y, MA tllg5rj `Ilodr.rseerrwy Not vuli(I without iit4nntule
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CERTIFICATE OF LIABILITY IN$URANCL
f _ TIFIGATE 13 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO FiIGHT5 IJPUM T HE FO RrED B TE HOLDER. THIS
CERTIFICATE DOES NOT AFPIRMA7IVELY OR NEGATIVELY AMEND,EXTEND OR ALTER 711E COVERAGE AFFORDED 8Y THE POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE UOES NO i'CONSTITUTE.A CONTRACT BETWEEN THE ISSUING INSURL-R(S),AU I HORIZED REPRESENTATIVE
ag-t P p t`E N CE . IF 0 lER
IMPORTANT: it the certlfic:atD hOldei is an ADDITIONAL INSURED,the pollcy(ies)must he endorsed. it SUBROGATION IS WAIVED,subject to the
lorinv and conditlons of the Polley,certain policleS may regniro and ondonewnent. A state I cnl on this certificate does not confer rights to the
Ic.ortifieale holder In liou of such ondorse—Als).
CON FACT
F•P.ODUffk I ! NAME.
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I 114CF.i\ flVlrS INS P,(.i(:1' PwoNE
(A+C No rxt): (AIC,ttol'
.. -- EMAIL _-- —_
PEA@O!'+`i. 1•L (li)ci0 ADDRESS'.
1,Y'Y �1NSOR01S)AFFORDINGCOVERAGE NAIG9
_. INSLIRLRAC iL.i., r,TFRIt S*I!CL- 'n:\*:CltC6h•pn>v':
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�IVACiiI fN. It(Jr7ALU UL<A PO NCO t.,i)4c,1'R.U:nr,,,
INSURER G: j
INSURER D'. j
INAURFR
!NSURF{
rovERAGES
CERTIFICATE NUIdBER; ... RPASION NUMBER:
IS ie Cf.H IFY i' TTr L'l SGF NSURANCELSTED BELOW HAVE BEER ISSUED TG THL II3UPLD KANFO ACOVF SCR'dF?OUCIPFWODINDICATED. NO'Y91H9TANOVIR '
ANY REQUIRENLNT,TF.RM OR CONDTTION OF ANY CONI PACT OR 0-I1ER DOCUNEN I WITH RESPECT 10"WCHTHIS CERTIFICATPMfY tSERCO OR MAY Kit VAIN TIULLCC RANGE
AFFONDE'U DY P.:Er0':ICI[SnFSCFtAiFp I I FREIN IS!,UBJFcT TO ALL THE TERMS.IXCLU31UDGA.iJLOY.ATIot4S(3r SUD"PULIC.IFS, Lu. S 5HO.VNTcAYnAVL OFF fr REUUC2D CY
rnm DLnw�.
ISQa Ann Sue _ POLICYFFr DATE 'OLICYWOAIE 41YRS
LIS TYPE OF INSURANCe L R POLIO 1,UFABEft !fA!l.1nL'YIYYYI ((MYIDDiriYYI �— —I
GENMAL LIABILITY
COMA-0ERC41L GENERALLwRlL)ll' WAGE 70 RENTED
CLAIMSt&,f)F ❑OCCUR. RE0.I:SES 1Ea cCCU"ranwi _...i
--��—_-- -- � _ENscnAL s ADv ua3uRY 's -
GEN'Lr.O1,RE.,2ATE I.Itl FT APPLIES PER. E N EF2AL AGGREGATE is _
r ` I T
' FOLICV F PROJFLT L�LCC RODUCTS-GJhiP10P AGG h
OOMRI4EO SINGLE
AUTOMOHILS LIAHILITY i
ANY A010 LIfd4T(E3 a,=IDr:N1p.�W—
I ALI.OVdNLDAUT05 3er per'NJL'R'f 18
SC11 c C)ilL E ALI 10i HODIIV INJURY
:-IlRuP AUCO$ � lF-drNGriCPnl)
PiLOPERT`!iIAF:MG? I'
120N OVJNFD AUTi):i
11 I(PcY accelenli
:I BRFi1.LA IJAB 00m: P, _ EACH pf,CURR[NCE
_ nGGPEGh'.F` _I�
FXGESS IInB L:Li1115-MA0E
DEUUC171BL.E
PCIFNT;ON S 1'
n'S aTUtux+ OTHER
A WORKERS COMRENSATION AND --� UH-(NRC•P012-L^. +.32W201i t0r7n1201A Lm'IfP
EMPI DYERS LIABiLITV (YIN
f tY PRLF'FNI UR'PARTNLR1FYLt UIUL {J NIA I An (.IDENT 00pBC ..
prFiceM4 Mhr.R CxcLUUGD. _f u.L.DISFJPA+S" FJ �P;IPLO/ S 1(10.Qil0 I
(M UaI�ryIH NiI)
Tye deault� Aae' L OISFA;c PI LILY LIMIT 1$ JfOE70
C L p.r I IOx C! OYh'MHC� o Jw .—_�_I —
UESCRIPTION OF OMERATIDN91t tRATIONSA'FHICLESIRESFRICTIONSISPECIAL ITEMS
�p1 "I RrrI n:ES .NlTRI")F.CI+2i r1 VEISSU':D'10 ]'PF.CIIITIFIL'ATE H01.I) R Afi-PCT r VORr3i° "O1 CL/'dfi 1
}+ IIaS1 R..DtiH NCNKERS u) GINSAtION YLt1.ILY i}Al il)I1h111BG OUILR ST1i;S':ND111«" ''lLi f U11fUFI�L1 Ih F4Yh FN LFILVG 1Tt)tIh I i
m.kDU,,iY FF{i lNcl3RLl3,b+A Ntl Nlt Li.$IN SIA I'6S OTiD.+T} W"NA. NO Al1T1 L" c: Ill IS fIVNV In IAY -IXINI!IACE FOP ISP+STUOIEM1 Eh
('1 f � r:P 1+ L+KLD t{IAFS Uk+{Ntti�IlKLJ F1+ll'l li'r'F FSl U75➢..L OF FICA FITS VI'1LiLl Pt E_P{(tl -n'1 L�.L 40YI RA('.:fOFk.t`4t S7 .I1.Jlf:7-k dA. t_4.
JS }
'r.ti.li.i�.,i;C:Oh11TN'SATIDN?0IXY DOES NOT PROVIDE U:)Y IAQIE OR.°ACIiLIN dVNnL'1_—) --
CERTIFICA"fE HOLDERl� —' CANCELLATION '
fiY.OULD Afff OF THE.ABOVE DBSGRIBFU F'OI_It%IES 9E GANCf:U.FD ,
IVTi ORf THE FXPIFiATON DATE THEREO!-,NOTICE WILL H�I�i 0
n I 1\: IS in li r nNCit Al CORQAN'r NITH T IE POLtcv flRov� (3N
V{)BGh. 111 AUII ORIZE REPREsfiNTATIVF.
NO wILKE5bUR01,Nf;
ACORD 25(2010105F, Tho AGORU name and laryo are repiatored mmarks of ACURp ! 59F}fjp 1'6 ACORD CURD RA1'I�}'L' A"�rHfhts rc,orved.
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STORE COPY
INSTALLATION SERVICES CUSTOMER CONTRACT- MWORK- INT/EXT/PATIO DOOR
LOWE'S OF DANVERS, MA., STORE# 1094 STORE PHONE: (978) 646-9099
153 ANDOVER STREET SALESPERSON: CHARLES VALENTE
DANVERS, MA 01923-1450 SALESPERSON ID: 1871016
Document Print Date: 09/01/2014
This is only a Quote for the merchandise and services printed below. This becomes an agreement upon payment and issuance of a Lowe's receipt, upon which the entire agree-
ment, including the specifically completed pages of this document, the Terms and Conditions included with this document, the applicable portion(s) of Lowe's receipt, and any
other addenda or attachments hereto,shall be referred to herein as this"Contract."
PLEASE READ THIS ENTIRE DOCUMENT. INCLUDING THE "TERMS AND CONDITIONS." BEFORE SIGNING.
Lowe's Registration or Contractor License Number/Lowe's Contractor Name
Lowe's Home Centers, LLC's MA HIC NO.: 148688 Lowe's Home Centers, LLC's FEIN: 56-0748358
Customer Name Home Phone
S DARSANA BARUA 978.745-7948
O Customer Address Other Phone
29 VALLEY ST
L City State/Province Zip/Postal Code
D SALEM MA 01970
Installation Address
T 29 VALLEY ST
O Installation City Installation State/Province Installation Zip/Postal Code
SALEM MA 01970
MERCHANDISE AND INSTALLATION SUMMARY
MERCHANDISE SUMMARY
1049: 87548 : STK : 1X4X8 RED OAK BOARD : 1X4X8 RED OAK BOARD : BABCOCK LUMBER - CITY 1
7001 : 24SCP.96 : STK : 2X4X96" TOP STUD : 2X4X96" TOP CHOICE STUD : CANFOR WOOD PRODUCTS MARKETING -QTY 2
CHOICE
19238 : 444 8PINE : STK : PNE CASE 444 5/8"X3-7/16"X8' : PNE CASE 444 5/8"X3-7/16"X8' : EMPIRE COMPANY, INC. (THE) - QTY 3
98543 : L 210 8FJPMD : STK : PFJ SHNG L210 1-5/8"X5/8"X8' : PFJ SHNG L210 1-5/8"X5/8"X8' : EMPIRE COMPANY, INC. (THE) - QTY 3
131207 : 131207 : STK : 1X8X16 PRIMED FNGR JNT (+333358) : 1X8X16 PRIMED FNGR JNT (+333358) : IRVING FOREST PRODUCTS (MAINE) - QTY 6
123961 : 13815LITETDLCLRPINE2 : SOS : SOS RB JW WOOD INT DOOR : STILE & RAIL PINE 15-LITE TDL FRENCH SYSTEM : JELD-WEN DIST - MW
MASTERS- QTY 1
326804 : PRODUCTCODE : SOS : SOS RB STN/STN DECO TXTFG TC DFAB : ENTRY/EXTERIOR SINGLE UNIT W 2 SIDELITES, 8 PANEL : DOOR FAB-
Store 1094 Project No. 419075616 for DARSANA BARUA Page 1 of 8
STORE COPY
RICATION SERVICES INC - CITY 1
Materials Price $ 2705.81
INSTALLATION DESCRIPTION
Stock or SOS : Stock Door Type : Exterior
Select Location : Front Door Select New Door : Single Pre-hung
Number of Doors to Install : 1 Side Lights or Transoms : Yes
Total Number of Side Lights and Transoms : 2 Hardwood (Mahogany or Oak) Door : No
Hidden Damage Description : None Number of additional holes bored for accessories : None
Install Specialized Mortise Hardware : No Install Storm Door : Install new storm door
Select Storm Door : Storm Door Lead Safe Practices : No
Total Linear Feet of Custom Trim to be Installed : 0 Deliver Door: Yes
Customer Understands Scope of the Project : Yes Permit Required : No
Additional Miles Traveled over 20 : 0 Bring Up To Code Description : None
Local Disposal Fee : Yes Describe Other Work Needed : close in sides , cut base , fix sit , add oak, cus-
tom ext. trim, b/i , b/o and install interior prehung french doors
Other Work Charge : Yes Comments : measure front entery and they want storm door with it and also they
need measure for interior french doors
Labor Charges 1 $ 2020.00
Detail Deduction $ 35.00
Additional Specifications:
Store 1094 Project No. 419075616 for DARSANA BARUA Page 2 of 8
STORE COPY
NOTICE TO CUSTOMER-PRICE CALCULATIONS: In order to properly perform the installation of certain Goods, the Contract Price may include more Goods
than actually will be installed based on the measured square footage of the Project Area. As a result, the parties agree that the lump-sum Price stated in this
Contract is calculated upon both the value of the estimated Goods required to fulfill the Contract (including waste), which may exceed the actual square footage
of the Project Area, and the labor which may be estimated based on the amount of Goods required to fulfill the contract (including waste). By signing this Con-
tract below, Customer acknowledges receipt of this notice and agrees and understands that the Price includes these costs which may not be refunded once the
Installation Services are performed..
TOTAL CHARGES OF ALL MERCHANDISE AND SERVICESwhere applicable
SUB-TOTAL $4690.81
*TAX $ 0.0
DELIVERY $ 0.0
ORDER TOTAL $4690.81
BALANCE DUE
Work is to commence upon reasonable availablity of Contractor which is anticipated to be Se g .7x/`[fill in date].
Estimated completion date is y 1 r ZK l�- [fill in date].
NOTICE TO CUSTOMER
All items listed in this contract and specification sheet(s) are to be installed under conditions agreed upon at time of purchase and at the price appearing
on this contract form. This assumes sound existing substructures, superstructure and points of attachments. Extra labor or material incident to installation
necessitated by defective substructures, superstructure, points of attachment, or the moving of fixtures or appliances to be billed at extra cost to Custom-
er.
IF THE CONTRACT T TAL IS $1,000.00 OR LESS Customer must pay in full.
C PLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS $1 000 00•
[M Customer to Pay in Full; OR
[_] Customer to use the following payment schedule:
(1) Deposit of $ to be paid upon signing contract. Any deposit collected at the time this Contract is signed will not exceed one-third (1/3)
Store 1094 Project No. 419075616 for DARSANA BARUA Page 3 of 8
STORE COPY
of the contract price; and
(2) Payment of $ to be collected upon or after the commencement of work. I/We authorize Lowe's to do one of the following (check ap-
propriate box below):
( ] Charge my/our credit card for the amount of the payment indicated above upon or after the commencement of work; or
[_] Deposit my/our check for the amount of the payment indicated above anytime upon or after the commencement of work; and
(3) Final payment of$100.00, to be paid upon completion of the installation to both parties'satisfaction.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND CONDITIONS CON-
TAINED IN THIS CONTRACT AND WHICH FOLLOW THE SIGNATURE PAGE(s). BY SIGNING BELOW, YOU ARE ACKNOWLEDGING THAT YOU
HAVE READ, UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH IN THIS CONTRACT. YOU ARE ENTITLED TO A COPY
OF THIS CONTRACT AT THE TIME OF SIGNATURE.
NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L. c.142A
LOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CON-
TRACT, THAT LOWE'S MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRET-
ARY OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUB-
!y:
. CH ARBIT ATIA NDAS PROVIDED IN M.G.L. c.142A. J r'
w""`� Date: �!i ae r 7_
o nt rs LLC q
v-, e:
-ram
By Date:
Co-owner or Witness
THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION
INITIATED BY I OWE'S PURSUANT TO M.G.L. c.142A. THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION
EVEN WHERE THE SECTION ABOVE IS NOT SEPERATELY SIGNED BY THE PARTIES
WITNESS OUR HAND(S) AND SEAL(S) BELOW THIS _DAY OF 5eat- 2y 1
Lowe's Home
'Centers, LLLC
B �/" 1 / (Seal)
Print Name: / � 4,e/
Store 1094 Project No. 419075616 for DARSANA BARUA Page 4 of 8
STORE COPY
Address (Seal)
Owner
rJue ✓g0. y) 91 ' '�I�R�An�rr� f3/� 2uA
City State/Province Zip/Postal Code Print Name
Co-Owner or Witness (Seal)
Print Name
Customer acknowledges receipt of a true copy which was completely filled in prior to Customer's execution hereof. You the customer may cancel this transaction
at any time prior to midnight on the third business day after the date of this transaction. See the attached Notice of Right to Cancel for an explanation of
this right.
Store 1094 Project No. 419075616 for DARSANA BARUA Page 5 of 8