12 FORRESTER ST - BUILDING INSPECTION (3) y
The Commonwealth of Massachusetts
a Board of Building Regulations and Standards CITY OF
SALEM
Massachusetts State Building Code, 780 CMR Mar
Revisedd Mar 1011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
VC, This Section For Official Use Only �•6 ,2k
Building Permit Number 'ALL .=k' rr - ' Date A " ed:
v
Budding Offrcia (Print Name) _" - `:; ; ,;" ;,.Sign .�5!: .-" Iat. ,mot'. ate
=:SECTION 1:SITE INFORMA N,'.^•� t'! '" °
1.1 Pr r[y Address: 1.2 As essors Map&Parcel No b s
i orreS-f- r ree-� g s 443
L 1 a Is this an accepted street?yes—v— no Map Number Parcel Number
1.3 on' g Informati M
V6' Di sions:1.4;a(tq
operty
In
Zoning District Proposed Use Lot ft) Fron a(fl)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Pr . ed Required P ded Required Pro d
1.6 Wa upply:(M.G.L c.40,§54) 1.7 Flo one Information: 1.8 S ge Disposal System:
Pu c❑ Private❑ Zon ' Outside Flood Zone? nicipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHiPr
2 wnertofR_. or _ . /.. a.. .,. ,
1.) rc . ' rneckl �em r 1�/l0. 019?U
Name(Print) City,State,ZIP
1 a Forre �r + 9Y8.39S, WA
No.and Street Telephone Email Address -
a SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all thafapply) ,!^'
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief DescriptA of Proposed W rkz: n
r
a
. . .. SECTION 4: ESTIMATED CONSTRUCTION
Item Estimated Costs: Of5mal:Use Only':' - x
Labor and Materials �•
I.Building $ 'd —1 ,,].'Building Permit Fee $ P. Indicate how fee is determined'
O Standard C.,,/Town Application Fee
2.Electrical $ " " `i -
❑.Total Project Cost (Item 6)x multiplier' _ x =.
3.Plumbing $ 2: Other Fees $UP,
4.Mechanical (HVAC) $ List "
5.Mechanical (Fire
$ Fees: r
( Total All
Check No. CheckAmount ' ==Cash Amount
6.Total Project Cost: $q a R 1 ❑paid in Full , ' T' ❑Outstanding Balance Due.
r'
SECTION 5:`CONSTRUCTIONS SERVICES W '
5.1 C rstruction supervisor License(CSL) Q"�1si (�
lr. ps ,Syec- Sears �3en 1 License[Number Expiration Date
ame of CSL Hol er
8Z`1 -r�o '1 b on p�Q List CSL Type(see below)
No. rid Street 1J Type ' Description
C 1 O 6 Z-1 /—y U Unrestricted(Buildings u to 35,000 cu.ft.
Q{� �S V / r R Restricted 1&2 Family Dwelling
City/T n,5 e,ZIP M Masonry
(i RC Roofing Coverin
WS Window and Siding
d SF Solid Fuel Burning Appliances
•p ulation
Telephone Email address D Demolition
5 Registereq Home lmprovemen[Co tracto (HIC) Mrs 10h)
148GD7 3
How HIC Registration p
e i tration Number Expiration Date
HIC Com an me or H g I Re i t Na e
1nZ4p prt roil----PQKrw �SYE-0231@Gr,,a I. cfln, .
i and Street �FL _ 5D W Email address
r n�uT 327
lf . J(/ 7t3 AS;Z
Ci /To r,State,ZIP Telephone
"' SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT`(M G.L,c1152.`§ 25C(6)) E.t
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 FOR BUILDING PERMIT --
rs
I,as Owner of the subject property,hereby authoriz WIE $ C-jGF ea
-
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(El ronic Signature) Date
---SECTION 7bibWNERr,;OR AUTHORIZED AGENT DECLARATION ' -
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true a ac ,rate to th est of my kno dge and understanding.
1 �l�os wEc 9�o Zo �3
Print Owner's or Authorized A 94Ve +mnuTttuc[mme tgna ure Date
NOTES. .. €..'
1„ An Owner who obtains a building permit to do his/her own work,or an owner who hires an unre ered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to a arbitration
program or guaranty fund under M.G.L.c. 142A. Other important information on the HI rogram can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be fo at www.mass. ov/d s
2. When substantial work is planned,provide the information below:
Total floor area(sq.R) 7- 1111
(ncldt g.ga ,finished basemenUattics,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 m Number of decks/porches
Type of co g system Enclosed Open
3. ctal Project Square Footage"may be substituted for"Total Project Cost"
i f
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CITY OF SiU EN1, TAXSSACHUSETTS
BI;=LxG DEP AR111ENT
120 WASHGVGTON STREET, 3�FLOOR
098" TEL (978) 745-9595
FA.e(978) 740-9846
rj
.,{BFRr F.Y DRISCOLL
MAYOR T HONW ST.PMRR6
DIRECTOR OF PUBLIC PROPERTY/BUILDNG COWMSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
tEP _7Tyc k I n a
(name of hauler
The debris will be disposed of in :
c►' I_� - r Gk i n__
(name of facility)
36S Una�v�. rs i y Av�vue
Wesh&OCO
(address of facility)
'PQ rS
signature ol permirlapplicant
�PIJ� ZO , ZO 13
(late
dcbri.lffdm
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The Commonwealth'of Massachusetts
Department of Industrial Accidents
Office of Investigations
600"Washington Street
BOSton,:MA 02111
www massgov/dia
Workers'.Compensation Insurance Affidavit:Builders/Contractors/Eleetricians/Plu fibers
Applicant Information Please Print Legibly
Name(Business/Organization/individual): Sears Home Improvement Products Incorporated
Address: 1024 Florida Central Parkway
City/State/Zip: Longwood, FL 32750 Phone#: 860-753-0452
Are you anemployer?Checkthe appropriate box:, Type of project(required):
4. ❑ I am a eneral contractor and 1.El I am a employer with g 6 ❑New construction
employees(full and/or part time).* have hired the sub contractors —
2.❑ I am a sole proprietor or:partner listed on the sheet I 7. ❑-Remodeling
ship and have.no employees These sub contractors have 8 ❑Demolition
working for me in any capacity. workers' comp insurance. 9 ❑Building addition
[No workers'comp. insurance 5 We are a corporation and its
required.] officers,have exercised.their 10 ❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemptionper MGL 11 ❑Plumbing repairs or additions
co c. 152, §1(4),and we have no
myself No workers' m (. ) .. 12 ' :Roof.. a...;
y [ P ❑ fir+
insurance required.] , employees [No workers' 13 1 Re IQCa, enf
comp insurance required.] Other —
*Any applicant that checks box Nl must also fill out the.section below.showing their workers:compensationpoliey information.
t Homeowners who submit this affidavit indicating they are doing:a1I work andthen hire outside contractors must submit a:new atticiavittnmcating such.
Contractors that check this box musta[tached an addillonal sheet showing the time of the sub contractors and theaworkers comp.policy information.
I am an employer thatis.providing workers.?,compensation insurance for,my;employees. Belorw,is;the policy.and job site
information.
Insurance Company Name: Ace American Insurance Company / Phone:866-283-7122
Policy#or Self-ins. Lie #: WLRC47322534 —� j� ExpiratiorrDatel 08/01/2014
t�
Job Site Address: 1 a For 1 C` 5fe r S1 1 e et ity/State/Zi V,
Attach a,copy of the:workers'compensation policy declaration page(showing the policy numberand expiration date).
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 fine
of up t63250,00 a;day against the violator. Be advised:thata copy:of this statement maybe forwarded to ihe`Office of
Investigations of the_DIA for insurance coverage verification.,
I do hereby eerti rid . thepainsand nalties ofperjury that the information provided above is true and correct.
Signature �ih99�_:� (Sears Auth.Agent) Date:S���- ZC2 . Z 0
r
Phone #: Home—Fax : 860-935-0346 / Cell: 860-753-0452
Official use only. .Do:notwrite in:this area; to.be:eompleted:l y 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.#:
t(
DAT 0(7MM0C13 )
le___ CERTIFICATE OF LIABILITY INSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS v
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES 0
RER(S),BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSU AUTHORIZED 3
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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 2
certificate holder in lieu of such endorsement(s). 'E
PRODUCER CONTACT y
NAME:
AOn Risk Services Central, Inc. ON (866) 283-7122 FAX (800) 363-0105 d
Chicago IL Office (AUG.No.Evq: INC.Na.: 9
200 East Randolph EMAIL
Chicago IL 60601 USA ADDRESS: _
INSURER(S)AFFORDING COVERAGE NAIC If
INSURED INSURER A: ACE American Insurance Company 22667
Sears Holdings Corporation INSURER Indemnity Insurance CO Of North America 43575
dba Sears Home Improvement Products, Inc
Attn: Risk Management E3-219A INSURER C:
3333 Beverly Road
Hoffman Estates IL 60179 USA INSURER D:
NSU0.ER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:570050796993 - 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. Limits shown are as requested
LTR TYPE OF INSURANCE INSR MAIDPOLICY NUMBER MMIDD/YYYY IULIOI MMIDDf e.1 UNITS
A GENERAL LIABILITY HDoG27022327 EACH OCCURRENCE $5,000,000
% COMMERCIAL GENERAL LIABILITY PREMISES Ea occugence $5,000,000
CLAIMS-MADE ❑X OCCUR MED EXP(Any one person) E%Cluded
PERSONAL S ADV INJURY $5,000,000
Do
GENERAL AGGREGATE $5,000,000 m
GEN'L AGGREG LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $5,000,000 ,o
X POLICY ATEPRO- LOC
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A AUTOMOBILE LIABILITY ISAH08719780 08/01/2013 08/01/2014 COMBINED SINGLE LIMIT W
A ISAH08719792 08/01/2013 09/01/2014 Ea arddert $5.000,000
A ANY AUTO ISAH08719809 08/01/2013 08/01/2014 BODILY INJURY(Per person) Z
X ALL OWNED SCHEDULED BODILY INJURY(Per accident) m
AUTOS AUTOS
NN-OWNED PROPERTY DAMAGE
X HIRED AUTOS % AUOTOS Peracudent
N
UMBRELLA LIAB OCCUR EACH OCCURRENCE O
EXCESS LIAB CLAIMS-MADE AGGREGATE
DED IRETENTION
A WORKERS COMPENSATION AND WLRC47322534 08/01/2013 OB O1 2014 )(I WC STATU- OTH-
EMPLOYERS'LIABILITY TORY LIMITS R
ANY PROPRIETORIPPRTNER I EXECUTIVE YIN CA MA AZ E.L.EACH ACCIDENT $2,000,000
B OFFICERIMEM6ER E%CWOEIo E] NIA WLRC47319122 08/01/2013 08/01/2014
IMyyandetor,in Nlq All other States E.L.DISEASE-EA EMPLOYEE $2,000,000
if
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $2,000,000_
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(AtucM1 ACORD 101,Addaional Remarks schedule,B more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
POLICY PROVISIONS.
Sears Home Improvement Products, Inc. AUTHORRED REPRESENTATIVE
1540 American Way
Longwood FL 32750 USA
(DI888-2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
d°ae ^ r1ca as `ram ' `
n� 3 Office of Cousu er Affairs and Business Regulation
10 Pack Plaza -,Suit' 5170
Boston; Ivlassac usetrts"0?116�
�
.yHoii e .I1npTove:: tment Contractor Kegistration
kg
Fr Regi9tration:b 148607 r
rrh`fr Type:,-,,Supplement datd
Expiration: 10/11/2013
SEARS HOME IMPROVEMENT PRODC1CT�hx � ,'
LUBOS 'SVEG N
1024 FLORIDA CENTRAL PKWY 1� .� � � � .,
LONGWOOD;FL 32760 "
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ry d *0
°w `� UpdatL Addrasti and re4irn card.es4ark reasoo For change..
""' Addreas '"s ReritrtY.rt a Employment „`Loo Card
:j`ly `brr+ezrxrtazerxrrrttl�i a, 2�rdx'�ee; - "d
DMICeof{1nrwmer Ansi ,&f9a1nr1bs Rugniatioo 111cease or r+egictration daiid for individof nse only -
11su;
HOINEYMPftOYEMENT CONTRACTOR before Die espiratida date.1t found return to-
> Re istratian Office of Consmner Affnirs and t3nsinecs Regulation
a 8 . #4B6m, Type: tUP;xr1c Pluz:r-finite Sl lQ ..„
"� �'��` Expiration 1Fr[17fx'O(t$ Supplement t;ard $asfan,h1$t#�k#ti : '
-SEARS HOME iMPR8VfzMF 1T PRODUCTS INC
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70�4 FLf1RlDACCNTRAi,,PKWY
F LONGWOOD, t 3a75i7 d
Ltn<#erseureiar} ' \nirgaiid reKllarH dignatarb. 4
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ti te1
Massachusetts.-De partmedFof Publ o Safety a '
3" 80ard of BuRding RegtrtaEions and Standards
-Ce�nstrucprin fiu perr-arpr �,g
'i License:GS-097519 r ..
LUBOSSVEC := ,•�^• 'r. .i :
r � 827 THOMPSON Y20�
t Thompson CT
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Commissioner 08/31/2014 k -
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r Illlflllll 111 III Office Location: BOSTON
Proposal Date 09/12/2013 lJobNumber 16213994 Sears Home Improvement Products,Inc.
Customer Name /^1 ^ P.O.Box 522290
1
EDWARD CZARNECKI / J 024 Florida Central Parkway
Customer's Home Phone Customer's Work Phone Longwood,FL 32750-7579
(978) 395-5494 Home Improvement Products
Phone(806 469-4663
Street Address ESTIMATE AND PROPOSAL Contractor License/Registration Number
12 FORRESTER ST MA(148607)
City State Zip code Windows All plumbing and electrical services performed by
SALEM MA 01970 Is installation within city limits? licensed subcontractors
Installation Address County ESSEx (Yes/No): YES FEIN 25-1698591
Billing Address(if different from above) City State Zip Code Project Consultant Name 8 License No.(if applicable)
NEAL FISCHER BOSTON
Description of the Project and Description of the Si nificant Materials to be Used and E ui merit to be installed
1 Remove existing units to be replaced.(PLEASE NOTE:The removed units are likely to be damaged.)
2. Prepare openings as necessary to receive replacement units.(No finish work other than normal installation is to be done unless otherwise noted below.)
3. Installation includes the clean-up of all job-related debris upon completion of the job.
4. (If applicable)After the completion of the project,the customer will be responsible for the application and removal(storage)of shutter panels. In the event
that the project requires the installation of storm shutters or egress windows, Sears Home Improvement Products, Inc. ("Sears") will not re-install any
affected security bars.
5. (If applicable)In the event Sears is unable for whatever reason to obtain the proper permits prior to the commencement of any work,Sears will refund any
previous payment and this contract will be automatically cancelled.
Summary of Window Order Addendum(see detailed Window Order Addendum for more information):
Type: We LTD (WINCORE) Quantity: 6
Type: Quantity:
Type: Quantity:
Type: Quantity:
Type: Quantity:
The Window OrderAddendum is made a part of and incorporated into this contract by
Customer(s)initials
reference. �G
Additional work to be done:N/A
Work NOT to be done:
REST OF WINDOWS
SPECIAL INSTRUCTIONS:WINDOWS DO NOT HAVE THE TAB LOCKS ON THEM
All of the above check boxes, "Work NOT to be done," "Additional work to be done," and Customer(s)initials �C"Special Instructions"sections have been reviewed and explained to me.
SW1-MA (Dig.) Rev 08/13/12 Page 1 of 3
Job Number: 16213994
APPROXIMATE START DATE and APPROXIMATE COMPLETION DATE:
The work vdll start approximately 4-8 WEEKS (Approximate Start Date)
It will be substantially completed by approximately 1-2 DAYS (Approximate Completion Date)
These dates are subject to change at the time the contract is accepted by Sears Home Improvement Products, Inc. ("Sears")or at any other time by mutual
written agreement. Customer understands that the Approximate Start Date is only an estimated date and the Customer will be contacted prior to this date to
schedule the actual start date.
ASBESTOS ABATEMENT: This Estimate and Proposal assumes that there are no asbestos containing materials("ACMs")that would be disturbed in the
performance of the installation work. If upon further inspection by the contractor or others it is learned that ACMs have to be disturbed to perform work,then
Customer must arrange and pay for abatement of asbestos by a qualified person prior to the start or continuation of work. If Customer fails to arran a for
necessary asbestos abatement within thirty (30) days, Sears may cancel this contract upon Customers)initials ��,
written notice to Customer.
The TOTAL PRICE including all labor,material,taxes and any applicable discount is$ 9,291.72 Contract Price ��$9,291.72
Initial Payment(not to exceed 30%of Total Price unless Special Order)$ 2,787.52 State Sales Tax( 0.00 %) $ 0.00
Final Payment(balance payable upon completion of job)$ 6,504.20 Local Sales Tax( 0.00 %) $ 0.00
The Initial Payment is due prior to Sears ordering products. Total Amount Due $9,291.72
The form and method by which the Customer(s)will pay is described in a separate Cash/Credit Customer(s)initials
Card Payment Addendum made a part of and incorporated into this contract b reference.
NOTICE TO BUYER: YOU, THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY
(FIFTH BUSINESS DAY IN ALASKA, FIFTEENTH BUSINESS DAY IN NORTH DAKOTA IF YOU ARE AGE 65 OR OLDER)AFTER THE DATE OF THIS
TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT,
ADDITIONAL PROVISIONS
Proposal and Approval.Sears offers to furnish the materials and arrange for their delivery and installation as specified on the first page and/or the attached
sketches and specification sheets for the TOTAL PRICE shown.This offer must be approved by the Installation Department. If this is a credit sale or a payment
on completion sale,it must be approved by the Credit Sales Department. If this proposal is not approved or the installation cannot be made in accordance with
the law,this offer will be withdrawn and any payments you have made will be refunded to you.Any materials left over after the installation has been completed
are Sears property and will be removed by Sears.
Installation. I understand that Sears will not install the materials but will arrange for the installation. Sears is not responsible for materials or installation NOT
furnished or arranged by Sears.Sears'installation contractor(s)will obtain all building permits required by local law. For homes located in historic or landmark
zoning districts,Customer will be responsible for obtaining required approvals and related permits prior to the commencement of work on this contract.
Authorization. I authorize Sears to: (1)arrange for a contractor(licensed where required by law)to make the installation of materials; (2)issue a work order
for this installation to a contractor; (3)inspect the installation;and (4)pay the contractor when the installation is complete if I have signed a certificate that the
installation has been completed to my satisfaction.
Delays in Installation.I agree that Sears is not responsible for delays in delivery or installation due to weather,fire,strikes,war,government regulations or any
causes beyond Sears'control.
Oral Agreements and Changes in Contract.I understand that there are no oral agreements between Sears and me.Everything I expect Sears to do has been
included in writing in this contract.Nothing can be changed in this contract unless it is in writing on a separate form accepted by me and Sears.
Responsibility of Buyer. I agree that any information or measurements that I give to Sears are correct and complete. I am responsible for any special work
described in this contract.
Electrical&Plumbing Service. I will provide adequate electrical and/or plumbing service(s)to run any newly installed appliances or other furnishings. If the
electrical and/or plumbing service(s)do not meet the standards of the utility company or electrical and/or plumbing codes, I will make the necessary changes at
my expense unless Sears has agreed in this contract to make the changes.
Payment.I will pay Sears the cash price that covers the price of material and installation as shown on the first page.
Warranty Information.Appropriate product warranty documents will be given to me by Sears.Sears'Warranty on Installation is:
SEARS'LIMITED WARRANTY ON INSTALLATION
In addition to any manufacturer warranty extended to you on the product(s)used(which warranty becomes effective the date the merchandise is installed),if the
workmanship(or application)of any Sears'arranged installation proves faulty within(i)one year for Weatherbeater Value Line, (ii)two years for Weatherbeater
Plus,or(iii)three years for Weatherbeater Max,and Weatherbeater Stormbeater,then upon notice from you Sears will cause such faults to be corrected by repair
at no additional cost to you. If Sears determines that repair is not commercially practicable or cannot be timely made,then,at Sears'sole discretion,Sears may
elect to provide replacement or refund.Service under this Limited Warranty is available by calling Sears Home Improvement Products at 1-800-222.5030,
Option 4.This warranty gives you specific legal rights,and you may also have other rights that vary from State to State.
SW 1-MA (Dig.) Rev 08/13/12 Page 2 of 3
• �I�I�II If"I�I�� Job Number: 16213994
NOTICE TO BUYER
1. DO NOT SIGN THE AGREEMENT IF ANY OF THE SPACES INTENDED FOR THE AGREEDTERMS TO THE EXTENT OF THEAVAILABLE INFORMATION
ARE LEFT BLANK.
2. YOU ARE ENTITLED TO A COPY OF THIS AGREEMENT AT THE TIME YOU SIGN IT.KEEP IT TO PROTECT YOUR LEGAL RIGHTS.
3. YOU MAY PAY OFF THE FULL UNPAID BALANCE DUE UNDER THE AGREEMENT AT ANY TIME,AND IN SO DOING YOU SHALL BE ENTITLED TO
A FULL REBATE OF THE UNEARNED FINANCE AND INSURANCE CHARGES.
4. YOU MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY[FIFTH BUSINESS DAY IN ALASKA,
FIFTEENTH BUSINESS DAY IN NORTH DAKOTA IF YOU ARE AGE 65 OR OLDER]AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED
NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. FAILURE TO EXERCISE THIS OPTION, HOWEVER, WILL NOT
INTERFERE WITH ANY OTHER REMEDIES AGAINST THE RETAIL SELLER YOU MAY POSSESS. IF YOU WISH, YOU MAY USE THIS PAGE AS
NOTIFICATION BY WRITING"I HEREBY RESCIND"AND ADDING YOUR NAME AND ADDRESS.A DUPLICATE OF THIS RECEIPT IS PROVIDED BY
THE SELLER FOR YOUR RECORDS.
5. IT SHALL NOT BE LEGAL FOR THE SELLER TO ENTER YOUR PREMISES UNLAWFULLY OR COMMIT ANY BREACH OF THE PEACE TO
REPOSSESS GOODS PURCHASED UNDER THIS AGREEMENT.
NOTICE TO MASSACHUSETTS RESIDENTS ONLY
In addition to the Notice to Buyer shown above, Massachusetts law requires that contracts for home improvement work state that all home improvement
contractors and subcontractors shall be registered and that any inquiries about a contractor or subcontractor relating to a registration should be directed to:
Director,Home Improvement Contractor Registration
P.O.Box 871
Taunton, MA 02780-0871
Telephone:(508)821-9375
Please note that owners who secure their own construction-related permits or deal with unregistered contractors shall be excluded from access to the
Guarantee Fund.
Notwithstanding any other language in the contract or associated documents, Sears will not remove, replace, or install any heating
or air conditioning system, or any portion thereof, if asbestos or asbestos-containing material is known or likely to be present in that
heating or air conditioning system,or any portion thereof. If it is determined or reasonably suspected that asbestos is present, either
before commencement or during performance of the work, it shall be the customer's responsibility to select, retain and pay all costs
of a Division of Occupational Safety ("DOS") licensed Asbestos Contractor to remove all asbestos or verify that none is present in
the components involved in the job. If the determination or reasonable suspicion of the presence of asbestos arises after Sears has
started the work,Sears will immediately cease performing the work until a DOS licensed Asbestos Contractor, hired by the customer,
removes all asbestos from the components scheduled for repair or replacement in accordance with 310 C.M.R. 7.00 and 453 C.M.R.
6.00 or verifies that none is present. By signing the contract the customer agrees that it understands the above.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
09/12/2013 09/12/2013
Customer's signature Date Customer's signatupre1 / Date
Accepted by Sears Home Improvement Products, Inc.("Sears")on 09/12/2013 by. )l,f
Date Management Representative
SWI-MA (Dig.) Rev 08/13/12 Page 3 of 3
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JOB NUMBER: 16213994-0001
PROPOSAL DATE: 9/12/2013
WINDOW ORDER ADDENDUM
1 W-SLIDER 2 64 W X 58 H
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LOWE/ARGON/CLEAR
FULL SCREEN - -'
2 W-ENDVENT 2 79 W X 56 H
WHITE
1/4-1/2-1/4 END VENT
LO W E/ARGON/CLEAR - -HALF SCREEN
3 W-SLIDER 2 56 W X 55 H
WHITE
LOWE/ARGON/CLEAR �I
FULL SCREEN _
TOTALS: 6
COMMENT:
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