14 FOSTER ST - BUILDING INSPECTION c,r- i®tea
i t 1-2o rV)
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
I Massachusetts State Building Code, 780 CMR Revised,Ilur 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only '
Building Permit Number: Date Appl' dt
building 011icial(Print Nmne). . . Signature. D'r<�'
r SECTION 1:SITE INFORMATION
(� LI Property Address: i fJ F L2 Assessors Map& Parcel Numbers = m
4 / c�
1.1 a Is this an accepted street?yes no_ Map Number Parcel Number
rn
1 1.3 Zoning Information: 1.4 Property Dimensions: D 'n
n T �
J / Zoning District Proposed Use Lot Arco(sq II) Frontage(11)
1.5 BuildingSetbacks(R)
n(� Front Yard Side Yams Rear Yard
I I 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❑ y
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
I Check if es❑ P p
SECTION PROPERTY OWNERSHIP.'
2.1 Owner'or Record ar I�S fViln2-2 '�Cn 12tM I q
�hme(Print) City,State,ZIP
1 Ll R3W Sd_ c -7 —9y3— th99
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ I Addition ❑
Demolition ❑ Apoi-s-ok Bldg.❑ Number of Units rOther ❑ Specify:
Brims esc{�tjon od'�r d W r =.
Ivn
a
SECTioi i-ESTENIATED CONSTRUCTION COSTA
licm Estimated Costs: Official Use Only
Labor and Materials)
I. Building S D I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2?Other Fees: S
4.Mechanical (FIVAC) $ List:
S.i\Icchanical (Fire S Total All Fees:S
Su ression)
Cheek No._Check Amount: Cash Aumnnt:
6. Toad Project Cost: $ y �p2 13 Paid in Full 0 Outstanding Balance Due:
r
SECTION 5: CONSTRUCTION SERVICES 16
5.1 istructioii Supervisor L!cciise(CSL) ��9 a— �A
License Number Expiration Date
Nanic of CSL Holder' l.•
r f
l� W I1�crs ` List CSL'Type(see below)
1 Type' �� �- - Description
No. and Street I� _
U Unrestricted Ouildin s up;to 35,000 cu. It.)6v" R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Rooting Covering
WS Window and Sidin
�j SF Solid Fuel Burning Appliances
y�l 699, Q f l(3l I Insulation
Telephone Email address D Demolition y
5.2 Registered Hour improvement Contractor(HIC) l a �l3 —3—/
u N t-ti*2 �� ( HIC Registration Number . Expiration Dale
fJ1�C rap �S pT'�p r 111C iJr�str �1e
�D
vid S
Email address
' 504uee y��r�✓�r� YN-6g9t- kg3q
City/Town, State ZIP Telephone
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 AUTiMUTION70 BE COMPLETED-WHEN'
OWNER'S AGENT OR CONTRACTOR fAPPLIES FOR BUILDING PERMIT`
1,as Owner of the subject property,hereby authorize (lUl� i Il Q 9b+
t9 act on my behalf,in all matters relative to work authorized by this building permit lipplication.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or 4 hortzed Age is Name(Elea runic Sigrmtur ) Date
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 guarmity fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
leww.m SS.eov'oea Information on the Construction Supervisor License can be found at www.mass. ov:! .
2. When substantial work is planned,provide the information below:
'total fluor area(sq. a.) ,(including garage, finished basement/attics,decks or porch)
Gross living area(sq. it.) Habitable roam 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 Enclose) Open_
i. "foul Project Square Footage"may be substituted for"Total Project Cost"
The Common ivealth of Massachusetts
— Department of Industrial Accidents
Office of Investigations
- = 600 Washington Street
''-' ,•:'` Boston,MA 02111
wnumniass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Or=anizatiun!Individual): O.'e, o Ak wme_
Address:__ 09 6 o 4" fivt-tvP1K�
City/State/Zip: S4vm Phone #: SO OX2-
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. M I am a general contractor and I 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 attached sheet.< 7- ❑ Remodeling
ship and have no employees These sub-contractors have & ❑ 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 exemption per MGL I L❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152,$1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers'
comp.insurance required.] 13�]Other �ac2Vnen
Itf W
'Any applicant that checks box N I must also fill out the section below showing their workers'compensation policy information.
t Nomcowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
`Contractors that check this box must attached an additional sheet showing the time of the subcontractors and their workers'comp.policy information.
l ant an eaipki,er brat is prtSvidiilg workers'compensation irisuratrce for iliy employees. Below is the policy and jab site
htforulation. �,// `I
Insurance Company Name: a`�j ter//�/ 1��,/fly 5 ✓O
Policy f or Self-ins. Lie.#:W Ci O / / 3 y ( Expiration Date: 3 aO�b
Job Site Address: I I F6.54� 5�-- City/State/Zip: Spke M Mi
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition orcriminal penalties of a
fine up to S 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 c�ert under the painsands penalties of perjury that the information provided above is true and correct
Sign t/i�fy ature: ' w,1& Date:
Phone#: 5 / (O 7
Ofjtcial use only. Do not write in this area,to he 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 S.Plumbing Inspector
6.Other
Contact Person: Phone#:
A`��® CERTIFICATE OF LIABILITY INSURANCE °o7124,20115°D "
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 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
MARSH USA,INC. NAME:
TWO ALLIANCE CENTER PHONE FAX .
3560 LENOX ROAD,SUITE 2400 •MALL Nor
ATLANTA,GA 30M ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC9
1 W492-HDmeD-GAW-15-16 INSURER A:Steadfast Insurance Cmpary 26387
INSURED INSURER B:ZUDM Amman ItSDtanW Co 1�j
THD AT-HOME SERVICES,INC.
DBA THE HOME DEPOT AT-HOME SERVICES INSURER C:New HampsMre Ins Co 23841
2690 CUMBERLAND PARKWAY,SURE 300 ATLANTA.CA 30339 INSURER D:Illinois National Insurance Company 23317
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: ATL-M4268509 REVISION NUMBER:7
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NONNTHSTANDING 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 SUER POUCYEFF POUCVEXP
LTR TYPE OF INSURANCE POUCYNUMBER MWDDNYYY MM UNY
M LA11T5
A GENERAL LIABILITY GLO48877144D5 0310112015 0310172016 EACH OCCURRENCE It 9,000.000
X COMMERCIAL GENERAL LIABILITY PREMISES LE3 occurrence S 1,000,000
CLAIMS-MADE MOCCUR LIMITS OF POLICY XS NED EXP(Any am person) $ EXCLUDED
OF SIR:$1M PER OCC - PERSONAL S ADV INJURY $ 9,000.000
GENERAL AGGREGATE $ 9.0W.0DD
GEN'L AGGREGATE UMITAPPLIES PER: PRODUCTS-COMFMPAGG S 9,00D,000
X POLICY PRO- LOC
B AUTOMOBILE IIgBILRY BAP 293B86312 IXV01I2015 03N12016 COMBINED SINGLE LIMIT 10�OW Ea accident S
X ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG
AUTOS AUTOS BODILY INJURY(Per accident) $
HIRED AUTOS AUTOfJ-OOSWNED PROPERTY DAMAGE $
Peraccidem
$
UMBRELLA UAB BUR EACH OCCURRENCE $
EXCESS LVIB CLAIMS-MADE AGGREGATE S
DED RETENTION$ S
C WORKERS COMPENSATION WC017731493(AOS) 03f0112015 03N12016 WC 5TATll OTH-
ANDEMPIDYERS'LWBLLITY YIN O R
O ANY PROPRIETORIPARTNERIIXECUTNE WC017731495(AK,KY,NH.NJ.VT) 031D12015 031012016 EL.EACH ACCIDENT $ 1,000,OOD
D OFFICER/MEMBER IXCLUDBD7 NIA
(Mandatory In NH) WC017731494(FL) 03101/2015 03fOV2016 E.L.NSEASE-EA EMPLOYEE $ 1,00D,000
It yea,descdee under Continuedon AtldBorel Pa e DESCRIPTION OF OPERATIONS ham 9 EL.DISEASE-POLICY LIMIT $ 1,000,OfX)
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,AddNimal Remmits schedule,N more space Is required)
EVIDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
THD AT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
DBA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS.
ATLANTA,GA 30339
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Manashi Mukheriee .Mauallona A,e�a.u,d-r,1,
0 1 988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
U` Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Cunvtruction Superriaor Specialty
License:CSSL-0D>�699 ELI;
,i
ROBERT POCZO$UT --- 's
172 WHALERS EM
Salem MA oly
Expiration
Commissioner 021061 16 '
4
6
' 1 A
0iitice of ICoi�surner Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Horne Inrprovera,p>zti;,Contractor Registration
Registration: 126893
it Type: Supplement Gam
Expiration: 8/3/2016
THD AT HOME SERVICES, !NC.. L_.....:
MARK NIADNA
2690 CUMBERLAND PARKWAY
ATLANTA, GA 30339 :
Update Address and return card.Mark reason for change.
scn i ., auM•as,n
'• ID Address (_j Renewal [] Employment Lost Card
LL r:�/,r Yrrn,,,,uaenere/I/,�rJlu.;�,ir•/rn,c•�L,
"==- Officc of Consumer Affairs t&Business Regulation License or registration valid for individul use only
it RMOJO
before the expiration date. 1f found return to:
OME IMPROVEMENT CONTRACTOROffice of Consumer Affairs and Business Regulation
Realstratian::.:126r.893, . Type: 10ParkPlaza-Suite5170
:e�- Expiratio.'jl;;-;613(20;1.6- Supplement Card Boston,MA02116
THD AT HOME SERVICES;.INC: ,
.. THE HOME DEPOT.AT4. DM'E'SERVICES
MARK NIADNA
2690 CUMBERLAND F141(MA S
XfarM.GA 30339 Undersecretary — t valid without Signature �—
• - 1
1
I
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a
CITY OF SALE4 MASSAaiUSEM
BUILDING DEPARTMENT
120 wASHINGTONS9REET,3mFT.00R
TkL(978)745-9595
KRaERLEYDRISCOLL FAX(978)740.9846
MAYOR '11: CMM STJp ERRS
DIRECTOR OF PUBLIC PROPERTY/BUILDING ODIvWSSIONER
Construction Debris Disposa/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 c40, S 54; Building Permit ff is issued with the
condition that the debris resulting from this work shall be disposed of in a Properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by: 0 0 Z --*b� -MOLK
(nameS �cc.(``�-i�r
of hauler)
The debris will be disposed of in: 6uL_6 � �
(name of facility)
(address of facility)
Signature of a plicant
IT-1 -
Date
Simonton Windows
6500 Vantage^ointe
—•""H` Do-tla-�ung rdl,m/I 1/8rr Glass Argon Loa;E No Lam;rated Glass
Vvith Grids
ha oral.`- Tnstrxv Venta,-a da doble guillotina Vinilo 3.18 mm V'idrio Argon-Lo+a!-E Sin
` 'rU'- J"r^ z. `ddric larninado COn reiNas
CPD.SSP-A-44-21042-00002 07-75 DH
ENERGY PERFORMANCE RATINGS
EVALUACION DE RENDIMIENTO ENERGETICO
U-ratter Solar Heat Gain Coe!f.c ent
`.=Iv CoeS;iar e.Ganar ra:E Br9rg a sale:
0.29 1 .65 0.24
ADDITIONAL PERFORMANCE RATINGS
a EVALUACION SUPLEMENTARIA DE RENDIMIENTO
Visible Transmittance
0.45
I
. I
13i"ar : II1Ja!E T3Iirate r9lac1191'v 9101G6 NFk prqsiiS.,-,O or dalar,n nng R c ie 0rtl•4i PelormariaN Cratriys are
6 6 .Or a W11 Sal„t erllolr enn.eontstar'sord a SoK -0oJuas ze.ri.-Ksoa, Nl'rfcl'llle '9ny protlLId J6610.W6r7e1liN
Ala:.<q of ant,G:odLcr:ar arty soE 5 ,rsa.Con,l. riarw ohnrs u:6t `cr otnor produc.pa are..°:Hurt ram..mw-nGr;,,xg
e 3R:arJa esllpu! o,av-lora3-x .Con 10,prateri 1- pneP9s.'. ;, ' ca,alernrz 'wsrhnr US aa!rrod.,:lo, 3,vo,,
;az Pa rN Rr sor.rol.r,liiac co ecre ,.eo@,o ce '..ior as era 3 ii n- sare.J 06 M1c-,mt 3Sp6c'.rIC FRO I:o racrOwds
ngJ, o.".co!y no iaren'Iza 4)ee rodul "B "ecoi?a,a,n wo eSpW T..O.Co.SL.!e:u,a 13JJ 7asbar pera el lQ6 eFropatlod6
es!e prodkl owe.nr-'.org
Y
Unit qualifies for ENERGY
STARS regim(s):Northern, -
North Central,South Central, ,
�. Southern.
R.,a. . 4y1f STC.29
Quifihed
IND: Rein 00/Glass ProSolar/H-LC25
Df':+25/-25
Tested Size:48"x 80"
Florida Product Approvai:FL5167
Applicable Test Standard(s): ANSI/AAMA/NIMNDA 101/LS.2-97,AAMA/WDMA/CSA
101/1,S.2/A440-05,AAMAA/VDMA'CSA 1C 14.S.2/A440-08,
r A440S1-09 Canadian Supp
8858790/01 g0333 HS Howard 6400094A
e o ace'.;; cle EkE3^f Jlsn�.e a!eo c ea..:- arav I uxa is gy;:a
�oarde�s.a hose 4 ocs glee ree MOO-os ENER 31 STARG Rem conTer as-ace ,'^e„e es!, visi!e A' uw.ene:^yser.gov.
"()MElMPROVEMRM'CONI'RACI'For-
c� PLF-ASF,I(EAUTHIS
lirunch Nance:ialtOn Ntatb&Routh ihne: 1 Sold,Furnished and Inswlted hy:
-- 'rHla At-Hun,Services,Inc.
"Much Number:31.and JJ NNa the Flnmc Depot At-Homc Se,,,,,
1)(gl Boston-1'umpike.Unit 1,Shrewsbury,MA 01545
Federal ID k 75 2 Tull Free g77-')13-17,X
bvW;ME❑c x C IRJ39:RI Can,LAN IAat7
i�c x tIIC.U56y522;MA H,dme Inymmtnent Caonacau Reg,g 12hyv3
Installation Address:
�E Ct1Y State Zip
Purchuseds):
Work Phone: Home Phone: Cetl Phone:
PT49Y3-cf6r��
Home Address:
(If different from Install-ion Address)
E-mail Add City Slate Zip
real wish
to
a my mout communications from Home Depot updates):
❑I W NOT wish to roccive any marketing emails from The Home Depot
Protect Information: Undersigned(-Customer"),the owners of the property located mthe above installation address,agrees to buy.
and THD At-Home Services-Ina('The Home Depot")agrces m fumi..h,deliver and arrange for the installation("Irtaallntion''r of all materials descriMd on the below and on the referenced Spec Shcet(s),all of which are incorporated into this Crmuact by this
reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively,
Contract"):
Jab n: a.
S SheN(s a: Protect Amount
Ring Siding Windows Inwtatim
f,J 0Cmmrs/Grvers OFsuy Doors ❑
Roofing Siding Windows Insulation
C]Guues/Covers [3EnuyDoors❑ 9:
Roofing Sitting WIIMa., Insulatoa
13Gulters/Covers i]Entry Doors❑ $
Roofing Siding Windows Insulation
❑OuMN/Covers ❑Entry Moors ❑ $
Mlydrmtmts9 Depttsh OrCwumn AnnumdmupwtexmNondMkmumet
` Maine Purchasers nay mdepodl morethan unNNtd Hatt Camino kmm. Total Contract Amount $ c
Customer agrees that, immediately upon completion of the work for each Product,Customer will execute a Completion Certificate
(One for each Product as defined by an individual Spec Sheep and pay any balance due. As applicable,each Customer under this
Contract agrees to be jointly and severally obligated and liable hereunder.
The.Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein.at
its discretion,if The Home Depot Or its authorized service provider delerminss that it canna perform its obligations due to a structural
problem with the home,environmental hazards such as mold,asbestos a lead paint,other safety ctmcems,pricing errors or because
work required to complete Ihejob was not included in the Contract,
Payment Summary: The Payment Summary fl��Q2 63 included as part of this Contract,sets forth the total
Contract ammtnt and payments required for the deposits and final payments by Product(as applicable).
NOTICE,TO CUSTOMER
You are entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(note:
there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product
Is complete.
In the event of termination of this Contract,Customer agrees to pay The Home Depot the casts of materials,labor,expenses
and services provided by The Home Depot or Authorized Service Provider through the date of termination.plus any other
amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acceptance and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer
mand 7he_Home Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements,either
oral or written;relating to said W01111106 Bad 1110114011.WIS AgreelHCnt canna be assigned or amended except by a writing signed
by Customer and The Home Depot.Customer acknowledges and agrees drat Customer has read,u ds,voluntarily accepts the
terms of and has received a copy of dils Agreement.`-
ACceLM
-g I1l11� by 4 6
Customer's Signature Date --- Sa hant's Sig anue Date
X Telephone No.
Customer's Signature Date Soles Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS (in appacabh)
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'SSTATE, '
NOTICE ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OFTHIS CONTRACT
I
I W07-14 Whae-Branch File Yenaw-Otmome
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