14 GENEVA ST - BUILDING INSPECTION The Conunonvvealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code. 780 CMR SALEM
? �. Revi.red.11ur_01l
Building Permit Application To Construct, Repair, Renovate Or Demolish a
Une-or Two-Fumilt,Dwellh
This Section For Official Use Only
Building Permit Number: ate Applied:
Building Official(Print Mane) Siyta re )ate
SECTION I:SITE INFORNIA
L't�p,r�o rty� A_ddres : 1.2 Assessors�Nlap & Parcel Numbers
41 s
1.1 a Is this an accepted street?yes_ no Map Numher Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Fr,poscd Use Lot Arca(sq R) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yards
Rear Yard
Required Provided Required Provided Required ProviJeJ
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Lone? Municipal ❑ On site disposal s stem ❑
Check't.v E P W" >'•
SECTION2: PROPERTYOWNERSHIP'
2.1 wnert of Record: q
le U,+rl) .CSS CAR Si1Gl-'�
N;une(Print) City.State,ZIP
!G G �r�vi+ s7 7'J�7�/Sc�ik7
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied O Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other O Sac'
Brief Description of Proposed Work':
Cr
SECTION 4: ESTINIATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Onl
(Labor and .Materials) y
I. Building I. Building Pemtit Fee: S Indicate how fee is determined:
'. Electrical g ❑Standard City/Town Application Fee
��� ❑Total Project Cost'(Item 6)s multiplier s
i. Plumbing S (f'-p'O 2. Other Fees: S --
4. Mechanical III%'k(•) S rJ Lis t:_
S. Mcchaniral IFirc
tiu t trcssionl S Total All Fees: S _ — _-- -
Check No. Check Amount: C ash Amount:
6. Total Project Cost: S0r11�21 -- --- - -
oraC I�Z�I/T7 ❑Paid in Full ❑OutstmtJing Ba
lance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number F%piration Dale
N;unc ol'C'SI. I lulder
p. List CSL r)Ile(sce belmv) _
_3 J✓�lS�_ V _ --- I)pe Description
No. and Street
lI 11nreslrictcd(BuiWin gs u133,5,1000 cu. 11.)
U(/�G�t(1L UAM R Restricted l�2 Famil DState.ZIP M1I MasonryRC' Ruffin g C'ovcrinW'S Window and SidinSF Solid Fuel Burning Appl
Insulation
'I'ele hone ('.mail address U I Demolition
5.2 Re/g�istered Home Improvement Contractor(HIC)
IIIC Registration Number licpiration Date
I IIC'Coil 11) Nam;or I IIC' lieg,, nl
Nu. rate Sucet,.�O U�G/�/I(b �iG S.513 5 v6 L'mail address
City/Town, State,ZIP O( 13 C 'relc hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 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 Owners Name(Electronic Signature) Date
SECTION 7b:OWNER' 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 and accurate to the best of my knowledge and understanding.
� fc,N/g/^t
II nu Owner's or:\uthorized Agent's Name ow.icclronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his,her own work,or an owner who hires an unregistered contractor
taut registered in the Hume Improvement Contractor(HIC) Program%will no have access to the arbitration
program or guaranty fund under I.G.L.c. 1 42A.Other important information on the HIC Program can be found at
pc.i Information on the Construction Supervisor License can be found at p>t t).)naac.yu) ,liis
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.t 1 including garage, finished basement'attics,decks or porch 1
Gross living area Isq. III.) - Habitable room count
Number of fireplaces__. Number of bedrooms
Number of bathrooms Number of half b;uhs
I%pe of heating s)stein Number of decks, porches
f)lie ofcoolings)Steil) frtclosed Open
3. •`total Project Square Footage'ntay he substituted tour"I'oLd Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
n u,.n:I r:10114,.11
I!�\lrAHNAGIU.\jlBCL•1• • j,1tFN, M.1\1d,.111 W I I,Jlvl:
I'h1. )4763-9393 s 1:1x
� 1 rllcan v7M•'iC•'la4A
��brki n' Cumpensatlon Insur�nce :lfllduvit: Builders/Cuntrecturs/Electrlclana/Plumbers
t In urrortlo
(� p' PI •rs int—Lem-1•bl
- ViIITICIIIuulkui Qr;lanvaliorvinJtrnluull:
1ddres..v 1,14 14 n
Cily,Sruc,7ipr GV1 ,-)dX/FG/ A, /9 Phone d: T.23
S
1 .tra)nil a ngrloye►1 Check 1he:glproprlale boa:
1. An)a cmpluydr with_[� 4. Q 1 ;un a dcncral contractor and t l y Pe of prolael(required):
�•Qcnlpluyccs(iull and/or putt-time).• huvt hired the rluh•cunlraciors b' ❑New construction
I.un u Solo prnpriclor or partner• listed on the anachcd sheet : 7. Q Reinodelin`
ship and have no mnpluycvs Tliess Jub•conrrsctors have
Linyu-It
fire ma in any capacity, ,vorken' comp, insurance
g' Q Demolirion
rs'comp. insurance J. ❑ We are n em 9• ❑Ouilding addition
porsrinn and its
oMccn have escieindd their 10.0 Electrical repairs or additions
etrwncr s*co all work right of 449111 i0n put MQL I I.Q Plumbing repairs or addirions
0 wprkcn'comp, e. 1J2,41(4),and we have n0
equired.) l employees. (No workers' I2•Q Ruul're-pairs
crnnp insurance myuind.l 17.Q Other
•,n>.pphrde IhW dwcks Iws eb mud:dw lilt uw Ihs.rclrou 6sluw dwWna
IAvir.wurkus'run,rretriiwr rylicy ulhutrotliun
'I l�nwnrwtvn,.1111 lu mlil this sllydsvil iwiutina Ili"are aain
•f,mtrwue•,11181 cMvk this Ilea m w alibrhod n11 addiiiuyl.Past dluw� d IrM ilicis uaitls him U rl,l►Caer rmtps mwl w1g1lil a new alrldsril indiQWiny WWII,
aeAria amp IkrM 4aAY1a•lUmv,prllry madmantdr./urn un euipleyrr thus Ir prvvlJ/nr iverkert'curnpenenr/on lnrnrrinee/br my emp/uyeer, Brry fi the pd/lay unp/u
/ul.rifr
in�dnndfGr4
Insurance Company Name: / (/ N•
141licy Al or Sclr-ins. Lic.H; OJL (f
Esptrillion
Jdb Sitc Addresr: //, G&FA/E// 0_ 5 Z
Attach a cu City'State/zip:
VY of the workers,cumpansaNua pulley declaration
m I ge(showln rife
I•Jllun to scwra cusenlde as squired uuJcr Section?Jr\ ul'\IGL c. 132 ca I N policy nwnbur and esplratlue dote).
in.up m 51 Jn0.rM ampur mte a lead to rife iinposition ol'cri ear im i urinal
Y r smllncn nahi p r, Jswcllascivdpcnalhamlhaf'unnu' � eau/a
afup to S'J0.00 a Jay Idainbi Iht vi-All"t Ufa ST(JP WORK W Ile advi.rcJ that DER and a fine atacu uflhu,t
nY Ylel ,I�JII ❑I! ul 110. IJI,\ Ibr Imur:u'cC enscrJyc ,cri ticahun. nuns may bit turw artluJ w the Ullice uC
/Jd/r.•n•Ay t rni�y rut lee the mill, per Girt ujprr/nry that the in urrnal/an/• prvriJeld ubdvt is use and Correct
\�.rp. IIII
Ir)j/lriu/toe duly, no nne rrile in dri.r aped. lu be ruuly/rted by City of to Vol u//Iriui
I�
( lily dr I'mrrl: _
- Pcnnirtl.leemr s
l,s uing .\uthurily (circla onu):
I. IG,JrJ If Ilrahh 1. Ihuldiny G. I)thrr Ilcp.utunml 1. Cil).Tunu Clerk 4. L'Icelric.11 layxclur plumping Imycelar
i
Information and Instructions
m+on In he service of ano[her un,ler any contract of hire.
�Lu;achu:eus t.icneral Laws chapter I i2 regW(Cs all Cllmg)IJyCr3I0 QfOY,de WUrlmCra CJ,upeO�iaUUn Ior IhClf elllp UYCC%•
I'uhu.ull to tills .1Atue, an emplufee is delined as"...a cry Dc .
elpress or onpi oral of wnrten." Jrolion ur tither legal entity,of Any Iwo or more
to erepluyI--er, delined u"an individual. partnership.Association.Cory
he
y tom eta loyees. However the
,�t the Grcegomg engage)m a)oil enterprise
And inducting he legal fCpfiaelllallvel Jt a dectased employer,or t
,ecerver ar it ntea of.m individual, Dlumenhlp,aasoclalion Jt other le Al i fes ,employing Y g ' P
e Hans w do maintenance,curtstruclian or repair work tin such dwelling{house
owner r a dwelling{house having not more than three Apartments and who resides therein,or the acupant of the
,Iwclhng house of another who employ Pe
or on 'lie grounds or building{ appurtenant thereto shall not because of such employment be deemed to be an employer.
had
,tIGL chapter 152. 425C(6) also stares that"every state or local llconslag agency Ill. Common the Ih for
o a or
ny
ce of lance with the Insurance coverage required:
renewal of a license ur permit to operate■buslneu air to construct buildinge la tQ;Commonwealth
I subdivisions shall
applicant who has not produ1e 175C(Il statesY Neither he commonwealth not any D
ol Addilianuily, SIGL clwpter l5_, S-
enter into any contract tot the perfomwn°of pit o the contract g authority."
requirementsofcumpliancewith the insurance
requirements of his chapter have been p' •
Applicants checking the boxes that apply to your situation and.if
addsess(es)and photo numbers)slang with lh&eeniffcate(,)of
Plc:use lilt nut the workers' compensation aty►davit completely. Y ces tither than the
necessary, supply sub-contructor(s)numal.4.'
worker' contpe,ssation imurance. if an LLC or LLP does have
inswvnca. Limited Liability Companies(LLC)or Limited Liability partnerships(LLP)with no employees
members or partners, are not required
e i�do car hat hie affidavit[nay be submitted to the Department of industrial
cmplayeas,a policy is req Department of
Ilealion for the gsonnit o license is biting rcqueated,not the Ihp
A xideeants for confirmation riqu re insurance. add coverage Alan De sure to alga and date the affidavit. T1e ,t)idavit shoo
he retuned to the city or town that he aDD aertions regarding the low ur if you are required to obtain u workers'
Industrial,\cuidenu. Should anti have any q
Campoustrial ite policy, pled call the Department st the number listed below. Self-insured companies should enter their
self-insurance license number on the a ro tiara lino.
CRY or'rown Officials
you to till out in the event the 011iee of Investigationa has to contact you regarding the applicant
Please be sure that the affidavit is complete :mJ printed legibly. The Department has provided u spun h the tines
of rho affidrvit fur y
given year, need only submit one aBidnvit indicating current
I'I:usc be sure ro till in the purmiUlicmrse nwngwr which will be used as a reference number. in addition,an applicant
That must submit multiple p innit,'licemtse applications in any g Y
Policy
information tit necessary)and under"Job Site Address"the applicant shnuW write":Ill locutions in (' Y
tawny"A copy Jf the ellldetvit that has been officially stamped or marked by de city or town nay be provided w the
ennil not related to any business or commercial venture
applicant as proof that a valid Affidavit is on rile for rotor*permits of licenses. A now a111davit nest be tilled out each
y ear. W here a homeowner or citizen is obtaining a license or p
i.e. ,r dug license it permit to burn leaves ere.) said person is NOT required to complete this utfida a hale•my yuasuons,
I he �)11ice tit I live stigatiums wuuld like W thank you in adrulce for your cooperation and should y
please du nut hesitate to give us a call.
rolcphone
er
fhe Ucparuncnt's address, aTh C mmonwealth of Maasaehusetu
Department of Industrial Accidents
Of1lae of Ievtestigadons
600 Waswigton Street
Boston, MA 02111
T'e1. 0 617-727-4900 ext 406 or I.877-MASSAFE
Fax M 617-727.7749
n l,s www.tnam.gov/tis
° CITY OF S.xI.&Nf, LtiL�SS.-kaiusETTS
BLLLDLNG DEPARTMENT
110 WASHNGTON STRIM, Yo FLOOR
ILL (978) 74&959S
F.Vc(978) 740-98U
Kld®ERLHY DUSCOLL
MAYOR THO..%Lu ST.Pmxxn
DIRECTOtt,OF PLOLIC PROPERTY/11LI DNG COMMISSIONER
Construction Debris Disposal AflIdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section t 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit At 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 ISOA.
The//debris will be transported by:
(name of hauler)
The debris will be disposed of in
J,j L /4t-
(name of factlity)
(addRss Of faclllty)
0S .Mire fpermitapplicant
R- �z
date
Lhn.,l(•I,w
SPECIAL SERVICES CUSTOMER INVOICE Page 1 of 11 NO. 2686-222171
Store 2686 SALEM,MA Phone: (978) 741-9299 VALIDATION
., 50 TRADERS WAY Salesperson: RFP452 Date: 07l08/2011 06:07 PM
SALEM, MA 01970 Reviewer:
Transaction: 2686 16 97192
Name Home Phone -
LESSOR RICHARD (978) 745-0487, Order Total: $22,s27.3s
• Amount Paid: $22,527.35
Access 16 GENEVA ST W Phan, (978) 821-2434
Company Name
• Pay Type: ELECTRONIC CHECK
city SALEM Job oesc Pfion 7/08 RTS KITCHEN
State MA Zip 01970 c°e"ty ESSEX
CUSTOMER PICKUP #1 MERCHANDISE AND SERVICE SUMMARY: sold`toc stomers9ht to limit the quantities of me andise
--- ------ -- - ----- - --- - -
REF# W11 SKU# 515-664 Customer Pickup/Will Call
STOCK MERCHANDISE TO BE PICKED UP:
REF# SKU QTY UM DESCRIPTION TAX ACH EXTENSION
R03 953-052 30.00 EA 5/8X5/8"NOCE/CHIARO MICORMOSAIC12X12/ $9.99 $299.70
R04 244-132 16.00 EA 4X12 NOCE CHIARO COPPER SCUDO LISTEL/ $11.98 $191.68
R05 240-196 32.00 EA 1/2X6" COPPER HALF ROUND ROPE/ Y $2.07 $66.24
R07 123-851 1.00 EA #382 BONE 10LB NONSAND GROUT/ Y $11.77 $11.77
R10 309-760 1.00 EA SIGNATURE PLUS SINGLE BOWL 9" DEEP/ Y $279.00 $279.00
S.O. MERCHANDISE TO BE PICKED UP: S/O FAUS GROUP INC. REF# S06 STIMATED ARRIVAL DATE: 07/20/2011
S0601 1 219-321 1 0.00 CAI FG8430 EMBOSSED/FG8430 EMBOSSED MBOSSED I Y $60.58 $605.80
SCHEDULED PICKUP DATE: Will be scheduled upon arrival of all S/O Merc s • $1 454.19
END OF CUSTOMER PICKUP -REF#W11
VENDOR DIRECT SHIP #1 0
TO: CU
D o0
FOR WILL CALL
MERCHANDISE PICK-UP
PROCEED TO WILL CALL OR
SERVICE DESK AREA
(Pro Customers, Proceed To The Pro Desk)
Page 1 of l l NO. 2686-222171 Store Copy
SPECIAL SERVICES CUSTOMER INVOICE-Continued Last Name: LESSOR Page 2 of 11 No. 2686-222171
VENDOR DIRECT SHIP #1
(Continued) TO: CUSTOMER
S/O- MERCHANDISE TO BE SHIPPED: S/O THOMASVILLE REF# S01 ESTIMATED ARRIVAL DATE: 0 810 5/2 01 1
REF# SKU QTY UM DESCRIPTION TAX PRICE EACH EXTENSION
S0101 502-754 1.00 EA APC/APC ALL-PLYWOOD BOX f 20% /APC Y $1 038.33 $1 038.33*
S0102 502-754 1.00 EA COFFEE/COFFEE COFFEE % /COFFEE N $936.61 $936.61*
S0103 502-754 4.00 EA TF696FH/TF696FH TALL FLR FULL HEIGHT 6W 96H /TF696FH MODS: W=96" N $93.72 $374.88*
W2=96" H=5" D=0 3/4"
S0104 502-754 2.00 EA TB8-WD14/TB8-WD14 TOE BOARD .25 WOOD/TB8-WD14 MODS: W=96" N $28.61 $57.22*
W2=96" H=4 1/2" D=0 3/8"
S0105 502-754 0.00 EA TF696FH/TF696FH TALL FLR FULL HEIGHT 6W 96H/TF696FH MODS:W=96" N $114.18 $0.00
W2=96" H=6" D=0 3/4"
S0106 502-754 4.00 EA SWLCRM8/SWLCRM8 SOLID WOOD LARGE CROWN MLDG/SWLCRM8 N $69.75 $279.00*
MODS: W=96"W2=96" H=2 5/16" D=2"
S0107 502-754 1.00 EA F330/F330 FLR 3W 30H/F330 FSIDES:B MODS: W=1 3/4" H=34 1/2" D=24" N $13.95 $13.95*
S0108 502-754 1.00 EA SB42/SB42 SINK BASE 42/SB42 FSIDES:B HINGES:B N $0.00 $0.00
S0109 502-754 1.00 EA BEPF3-WD/BEPF3-WD BASE END PNL WOOD 3 FLR (R)/BEPF3-WD FSIDES:B N $79.76 $79.76*
MODS: W=2 1/2" H=34 1/2" D=24"
S0110 502-754 1.00 EA OMC338424/OMC338424 OVEN MW CAB 33W 84H 24D/OMC338424 FSIDES:B N $985.82 $985.82*
50111 502-754 1.00 EA 3DB24/3DB24 3 DRW BASE 24/3DB24 FSIDES:B HINGES:B N $468.23 $468.23*
S0112 502-754 1.00 EA B36SS/ B36SS SLIDING SHF BASE 36/B36SS FSIDES:B HINGES:B N $687.14 $687.14*
S0113 502-754 1.00 EA SLS36L/SLS36L SUPER SUS 36 LH/SLS36L FSIDES:B HINGES:L N $895.68 $895.68*
S0114 502-754 1.00 EA W930L/W930L WALL 9W 30H LH/W930L FSIDES:B HINGES:L N $169.91 $169.91*
S0115 502-754 1.00 EA WQRES630STR/WQRES630STR WALL QTR RND SHF STRB 6W 30H/ N $123.77 $123.77*
WQRES630STR FSIDES:B
S0116 502-754 1.00 EA WQRES630STL/WQRES630STL WALL QTR RND SHF STRB 6W 30H/ N $123.77 $123.77*
WQRES630STL FSIDES:B
S0117 502-754 1.00 EA W2130R/W2130R WALL 21 W 30H RH/W2130R FSIDES:B HINGES:R N $231.43 $231.43*
S0118 502-754 1.00 EA W3615/W3615 WALL 36W 15H/W3615 FSIDES:B HINGES:B N $245.02 $245.02*
S0119 502-754 1.00 EA W2430/W2430 WALL 24W 30H 2DR/W2430 FSIDES:B HINGES:B N $292.96 $292.96*
S0120 502-754 1.00 EA W3618/W3618 WALL 36W 18H/W3618 FSIDES:B HINGES:B N 1 $267.561 $267.56'
***CONTINUED ON NEXT PAGE*"
Indicates
Page 2 of 11 No. 2686-222171 ' StoreeCarkdown
Copy
SPECIAL SERVICES CUSTOMER INVOICE - Continued Last Name: LESSOR Page 3 of 11 NO. 2686-222171
VENDOR DIRECT SHIP #1
(Continued) TO: CUSTOMER
S0121 502-754 1.00 EA W123OR/W1230R WALL 12W 30H RH/W1230R FSIDES:B HINGES:R N $179.93 $179.93`
S0122 502-754 1.00 EA DW302424SL/DW302424SL DIAG 30H 24W 12D SUS LH /DW302424SL N $335.16 $335.16`
FSIDES:B HINGES:L
S01 FR 506-658 1.00 KITCHEN CABINET FREIGHT N $250.00 $250.00
VENDOR-SPECIAL INSTRUCTIONS: LINE:THMASVIL DSTYLE:CAMDEN MAPLE USTYLE:CAMDEN-MPL LSTYLE:CAMDEN-MPL WOOD: APC FINISH: COFFEE
DSGNR:RFP452 FREE SINK BASE PER JASON BRODY
VENDOR WILL SHIP MDSE TO: ILESSOR, RICHARD
ADDRESS: 16 GENEVA ST CITY: SALEM
STATE: MA ZIP: 01970 COUNTY: ESSEX SALES TAX RATE: 6.250 • $8 036.13
PHONE: 978 745-0487 ALTERNATE PHONE: 978 821-2434 PAGER:
END OF VENDOR DIRECT SHIP
INSTALLATION #1
REF# 102
ESTIMATED INSTALL BEGIN DATE: 07/20/2011 ESTIMATED INSTALL END DATE: 08/25/2011
BASIC INSTALLATION LABOR:
SKU DESCRIPTION I QTY UM ITAXI PRICE EACH I EXTENSION
772-078 1 GRANITE 3CM-NAT/ 1 0.001 SFJ N 1 $0.01 $0.00
OPTIONAL LABOR SELECTED INCLUDES:
OPTION DESCRIPTION QTY UM TAX PRICE EACH EXTENSION
23 UNDERMOUNT INSTALLATION - STAINLESS STEEL (LABOR ONLY- FINISHED EDGE, 1.00 EA N $249.00 $249.00
MOUNTING AND CRADLE)/
25 ADDITIONAL SINK/COOKTOP CUTOUT UNPOLISHED TOPMOUNT/ 1.00 EA N $125.00 $125.00
67 `PROMO 6/23-7/10/11 NATL` FREE EDGE UPGRADE W/25 SF MIN PURCHASE. ORDER 10.00 LF N $0.00 $0.00
PAID BY 7/10-ADJUSTMENTS BY 10/2. NOT COMBINABLE W/SPECIAL BUY PROMOS.NO
CREDIT APPLIED IF OFFER REFUSD. STANDRD FAB & INSTALLATN CHARGES APPLY. LMT
1/H-HLD/GROUP B
CONTINUED ON NEXT PAGE
Indicates
Page 3 of 11 NO. 2686-222171 Store eCopyarkdown
SPECIAL SERVICES CUSTOMER INVOICE -Continued Last Name: LESSOR Page 4 of 11 No. 2686-222171
INSTALLATION #1
(Continued) REF#102
68 *PROMO 6/23-7/10/11 NATL* FREE COLOR UPGRADE W/25SF MIN PURCHASE. ORDER 42.00 SF N $58.00 $2,436.00
PAID BY 7/10.ADJUSTMENTS BY 10/2. NOT COMBINABLE W/SPECIAL BUY PROMOS. NO
CREDIT APPLIED IF OFFER REFUSD. STANDARD FAB & INSTALLATN CHARGES APPLY.
LMT 1/H-HLD/GROUP C
INSTALLATION SITE NAME: LESSOR, RICHARD INSTALL LABOR CHARGE: $2 810.00
ADDRESS: 16 GENEVA ST TRIP CHARGE: $0.00
CITY: SALEM STATE: MA ZIP: 01970 CREDIT FOR DEPOSIT/MEASURE: $0.00
COUNTY: ESSEX SALES TAX RATE: 6.250 TAX: Merchandise- N LABOR- N • $2,529.00
PHONE: 978 745-0487 ALTERNATE PHONE: 978 821-2434
BASIC INSTALLATION LABOR INCLUDES:
`IN HOME INSPECTION TO VERIFY LAYOUT,MEASUREMENTS,SPECIAL *EASED EDGE ON BACKSPLASH(ALL EXPOSED EDGES)
INSTALLATION REQUIREMENTS AND TEMPLATING *SUBTOP OR SUPPORT STRIPS
•BASIC INSTALLATION OF COUNTERTOP *GROUP A EDGE DETAIL
•ONE SINK OR COOKTOP CUTOUT(TOPMOUNT)PER PROJECT *FINAL CLEAN UP OF ALL DEBRIS RELATED TO INSTALLATION
•FAUCET HOLE DRILLING(UP TO 4 HOLES) *DELIVERY WITHIN 30 MILE RADIUS OF STORE
•WALL SUPPORT CLEATS AS NEEDED AT CORNER CABINETS
*EASED OR RADIUS CORNERS UP TO 3/4"MAX
UNLESS STATED ABOVE THIS INSTALLATION DOES NOT INCLUDE:
WINDOW SILLS/GARDEN WINDOWS AND PASS THROUGHS MILEAGE BEYOND 60 MILES FROM STORE ONE WAY
CABINET BUMP OUT REPAIR OR ALTERATIONS TO EXISTING CABINETRY
CUT AROUND POSTS OR ODD SHAPES WARRANTY ON TRAVERTINE,MARBLE OR HONED GRANITE
SUPPORT MATERIALS FOR OVERHANG(REQUIRED FOR OVERHANGS>6")
CUSTOM EDGES ON BACKSPLASH
END OF INSTALL#1
INSTALLATION #2
REF# 109
ESTIMATED INSTALL BEGIN DATE: 0 712 5/2 011 ESTIMATED INSTALL END DATE: 08/20/2011
Page 4 of 11 No. 2686-222171 Store Copy
SPECIAL SERVICES CUSTOMER INVOICE-Continued Last Name: LESSOR Page•5 of 11 NO. 2686-222171
INSTALLATION #2
(Continued) REF#109
MERCHANDISE TO BE INSTALLED:
REF# SKU QTY UM DESCRIPTION
R03 953-052 30.00 EA 5/8X5/8"NOCE/CHIARO MICORMOSAIC12X12
R04 244-132 16.00 EA 4X12 NOCE CHIARO COPPER SCUDO LISTEL
R05 240-196 32.00 EA 1/2X6" COPPER HALF ROUND ROPE
R07 . 123-851 1.00 EA #382 BONE 10LB NONSAND GROUT
S0101 502-754 1.00 EA APC ALL-PLYWOOD BOX j 20%
S0102 502-754 1.00 EAI COFFEE COFFEE
S0103 502-754 4.00 EA TF696FH TALL FLR FULL HEIGHT 6W 96H
S0104 502-754 2.00 EA TB8-WD14 TOE BOARD .25 WOOD
S0105 502-754 0.00 EA TF696FH TALL FLR FULL HEIGHT 6W 96H
S0106 502-754 4.00 EA SWLCRM8 SOLID WOOD LARGE CROWN MLDG
S0107 502-754 1.00 EA F330 FLR 3W 30H
S0108 502-754 1.00 EA SB42 SINK BASE 42
S0109 502-754 1.00 EA BEPF3-WD BASE END PNL WOOD 3 FLR f R
S0110 502-754 1.00 EAJ OMC338424 OVEN MW CAB 33W 84H 24D
S0111 502-754 1.00 EA 3DB24 3 DRW BASE 24
S0112 502-754 1.00 EA B36SS SLIDING SHF BASE 36
S0113 502-754 1.00 EA SLS36L SUPER SUS 36 LH
S0114 502-754 1.00 EAJ W930L WALL 9W 30H LH
S0115 502-754 1.00 EA WQRES630STR WALL QTR RND SHF STRB 6W 30H
S0116 502-754 1.00 EA WQRES630STL WALL QTR RND SHF STRB 6W 30H
S0117 502-754 1.00 EA W2130R WALL 21 W 30H RH
S0118 502-754 1.00 EA W3615 WALL 36W 15H
S0119 502-754 1.00 EA W2430 WALL 24W 30H 2DR
S0120 502-754 1.00 EA W3618 WALL 36W 18H
S0121 502-754 1.00 EA W1230R WALL 12W 30H RH
***CONTINUED ON NEXT PAGE
Page 5 of 11 NO. 2686-222171 Store Copy
SPECIAL SERVICES CUSTOMER INVOICE -Continued Last Name: LESSOR Page•6 of 11 No. 2686-222171
INSTALLATION #2
(Continued) REF 4109
S0122 j 502-754 1.001 EA DW302424SL DIAG 30H 24W 12D SUS LH
S0601 1 219-321 1 10.001 CA FG8430 EMBOSSED
BASIC INSTALLATION LABOR:
SKU DESCRIPTION I QTY I UM I TAXI PRICE EACH I EXTENSION
282-627 KITCHEN POINT-NAT/ 1.00I EAJ N 1 $0.011 $0.01
OPTIONAL LABOR SELECTED INCLUDES:
OPTION DESCRIPTION QTY UM TAX PRICE EACH EXTENSION
1 KITCHEN CABINETS WORKSHEET POINTS FOR DEMOLITION, DEBRIS REMOVAL, 226.50 EA N $29.00 $6,568.50
ELECTRICAL, PLUMBING AND APPLIANCES (UTILIZE THE KITCHEN POINT WORKSHEET
TO OBTAIN TOTAL NUMBER OF POINTS)/
2 PER CABINET INSTALLATION (INCLUDES WALL, BASE, PANTRY, PENINSULA OVEN & 13.00 EA N $69.00 $897.00
APPLIANCE CABINETS. INCLUDES SHELVES, FILLERS, SCRIBE, TOE KICK, HANDLES &
KNOBS.) KEY THE NUMBER OF CABINETS TO BE INSTALLED IN THE QUANTITY SECTION./
3 PERMIT AND ADMINISTRATIVE FEE QTY X $1.00 / 525.00 EA N $1.00 $525.00
5 PER POINT- PLUMBING AND ELECTRICAL ONLY/ 102.00 EA N $20.00 $2 040.00
INSTALLATION SITE NAME: I RICHARD LESSOR INSTALL LABOR CHARGE: $10,030,51
ADDRESS: 16 GENEVA ST TRIP CHARGE: $0.00
CITY: SALEM STATE: MA ZIP: 01970 CREDIT FOR DEPOSIT/MEASURE: $0.00
COUNTY: ESSEX SALES TAX RATE: 6.250 TAX: Merchandise - Y LABOR- N • $9 930.51
PHONE: 978 745-0487 ALTERNATE PHONE: 978 821-2434
BASIC INSTALLATION LABOR INCLUDES:
AN INSTALLER SITE ANALYSIS IS REQUIRED FOR PROPER FIT SITE ANALYSIS FEE IS APPLIED TO THE PURCHASE.
OF KITCHEN CABINETRY AND OTHER PRODUCTS TO BE INSTALLED. 'THE FINAL KITCHEN POINT WORKSHEET MUST BE SIGNED BY BOTH
DURING THIS CONSULTATION THE INSTALLER WILL CHECK FOR THE CUSTOMER AND STORE ASSOCIATE.A COPY OF THE FINAL -
UNUSUAL SITUATIONS WHICH MAY REQUIRE ADDITIONAL LABOR. SIGNED KITCHEN POINT WORKSHEET MUST BE GIVEN TO THE
`DAILY CLEAN UP OF JOB SITE CUSTOMER AND INSTALLER.
•THE SITE ANALYSIS FEE IS NON-REFUNDABLE
`IF CUSTOMER PURCHASES LABOR FROM THE HOME DEPOT,THE
UNLESS STATED ABOVE THIS INSTALLATION DOES NOT INCLUDE:
—'CONTINUED ON NEXT PAGE
Page 6 of 11 No. 2686-222171 Store Copy
SPECIAL SERVICES CUSTOMER INVOICE- Continued Last Name: LESSOR Page-7 of 11, NO. 2686-222171
INSTALLATION #2
(Continued) REF#109
ADJUSTING OPENINGS OR ANY WORK INVOLVING LOAD BEARING WALLS ALTERATIONS TO EXTERIOR OF HOME
REMOVE,ALTER OR BUILD LOAD BEARING WALLS(OTHER THAN STUD WALL REMOVAL OF VINYL FLOORING
FRAMING)
INSTALLING SKYLIGHTS
STRUCTURAL WORK
SPECIAL NOTES:
AN ADULT OVER 18 YEARS OF AGE WITH THE AUTHORITY TO MAKE CHANGE FURNACE FILTER BEFORE,DURING AND AFTER INSTALLATION.
DECISIONS ABOUT YOUR INSTALLATION MUST BE PRESENT DURING THE *WATER,GAS AND SEWER SERVICE MAY BE TEMPORARILY TURNED OFF
INSPECTION(WHEN APPLICABLE),DELIVERY AND INSTALLATION DURING THE INSTALLATION PROCESS. THE INSTALLER WILL NOTIFY
*NO WORK TO BE DONE ON SUNDAYS OR HOLIDAYS THE CUSTOMER OF AN ESTIMATED LENGTH OF TIME FOR THE SERVICE
`ALL WORK WILL BE DONE TO LOCAL CODES AND ORDINANCES TO BE UNAVAILABLE.
*ALL WATER AND GAS SUPPLY LINES MUST HAVE INDEPENDENT *CUSTOMER IS ASKED TO DESIGNATE PARKING,ENTRANCE AND EXIT
SHUT-OFF VALVES. ACCESS PREFERENCES FOR THE INSTALLER(INCLUDING RESTROOM
*JOBSITE MUST BE COMPLETELY ENCLOSED WITH ALL WINDOWS, ACCESS).
DOORS,INTERIOR WALLS,ROUGH PLUMBING AND ELECTRICAL WORK *CHILDREN AND PETS MUST BE KEPT AWAY FROM THE WORK AREA
COMPLETED PRIOR TO THE INSTALLATION *CUSTOMER IS RESPONSIBLE FOR ANY UNFORESEEN CONDITIONS
*THE WORK AREA MUST BE CLEAR AND ALL VALUABLES AND WHICH MAY ARISE DURING INSTALLATION.
BREAKABLES MUST BE REMOVED FROM THE WORKSITE PRIOR TO WORK *THE FINAL KITCHEN POINT WORKSHEET MUST BE SIGNED BY BOTH
BEGINNING THE CUSTOMER AND STORE ASSOCIATE.A COPY OF THE FINAL,
*CUSTOMER MUST UNDERSTAND THERE WILL BE A PERIOD DURING SIGNED KITCHEN POINT WORKSHEET MUST BE GIVEN TO THE CUSTOMER
THE INSTALLATION WHEN THE JOBSITE AREA WILL BE COMPLETELY AND INSTALLER.
UNUSABLE. *NOTE:THE HOME DEPOT DOES NOT PROVIDE THE FOLLOWING
*CUSTOMER MUST UNDERSTAND THERE WILL BE A PERIOD DURING SERVICES(AS PART OF KITCHEN INSTALLATION PROGRAM)
THE START OF THE JOB.OTHER ARRANGEMENTS MUST BE MADE BY *ADJUSTING OPENINGS OR WORK INVOLVING LOAD BEARING WALLS
CUSTOMER DURING THIS TIME FOR ACTIVITIES USUALLY HELD IN *REMOVE,ALTER OR BUILD LOAD BEARING WALLS(OTHER THAN
THE JOBSITE AREA. STUD WALL FRAMING).
*THE WORK AREA WILL BE CLEANED UP DAILY,BUT DUST AND *INSTALLING SKYLIGHTS
CONSTRUCTION RELATED DEBRIS AND NOISE WILL BE INEVITABLE *STRUCTURAL ALTERATIONS OR REPAIRS
THROUGHOUT THE INSTALLATION. *ALTERATIONS TO EXTERIOR OF HOME
ALL POSSIBLE STEPS WILL BE TAKEN TO MINIMIZE SPREAD OF *REMOVAL OF VINYL FLOORING
*"CONTINUED ON NEXT PAGE
Page 7 of 11 NO. 2686-222171 Store Copy
SPECIAL SERVICES CUSTOMER INVOICE - Continued Last Name: LESSOR Page-8 of 11, No. 2686-222171
INSTALLATION #2
(Continued) REF#109
WORK AREA DUST TO OTHER PARTS OF THE HOME.CUSTOMER SHOULD
END OF INSTALL#2
TOTAL CHARGES OF ALL MERCHANDISE & SERVICES
$21,949.83
SALES TAX $577.52
TOTAL $22 527.35
BALANCE DUE $0.00
END OF ORDER No. 2686-222171
Page 8 of 11 No. 2686-222171 Store Copy
Page 9 of 11 NO. 2686-222171
The Home Depot Special Services
Will Call/Direct Ship/Delivery
Returns: Except where prohibited by law, all returned Special Order Merchandise is subject to
a fifteen percent (15%) restocking fee. Custom made goods are not returnable.
Will Call: The Home Depot Store will call the number provided on the Invoice when Order is
available. A Will Call held at the Store for over thirty (30) days shall be subject to the
abandoned property laws in your state.
Direct Ship: Direct Ship merchandise will be sent by the vendor and/or manufacturer to the
address on the Invoice.
Delivery: Home Depot shall arrange for its Delivery Agent to deliver the Order to the address
identified on the Invoice pursuant to the following terms and conditions:
Roads Notice: The delivery address must be accessible by vehicle over roads and bridges rated
to handle up to and including (40) forty ton loads. If any portion of Delivery Agent's route must
traverse a section of road that is not rated to handle a forty ton load or heavier, Customer will be
responsible for seeking a waiver, at Customer's expense, from the appropriate governmental
authority. If Customer is unable to obtain a waiver, delivery service will not be available to the
delivery address.
Unattended Drop: If Customer will not be present to accept the delivery, and the delivery
can be left unattended, Please indicate by initialing below:
By initialing here, I authorize Delivery Agent to leave the merchandise
unattended following delivery and accept full responsibility for any resulting loss of, or damage to,
the merchandise.
Curbside Deliveries Only: You are purchasing merchandise that has been designated by Home
Depot for curbside delivery only. Your purchase does not include delivery beyond curbside, on-
premise or in-house ("Additional Services") or the installation/hook-up of merchandise ("Non-
included Installation Services"), and Home Depot has not authorized its Home Depot Delivery
Agent("Delivery Agent") to perform such Additional Services or Non-included Installation
Services. In the event you request, and Delivery Agent agrees to perform, Additional Services
and/or Non-included Installation Services, YOU ASSUME THE RISK OF, AND FULL LIABILITY
FOR, ANY RESULTING PERSONAL INJURY, DAMAGE TO PROPERTY, OR DAMAGE TO
MERCHANDISE. Also, any Non-included Installation Services shall void any express or implied
warranty provided by Home Depot and may void the manufacturer's warranty on the merchandise
so installed. By signing below, you acknowledge that you have read and fully understand
the terms of this waiver and release, and you intend it to be a complete and unconditional
release of all liability in regard to any requested Additional Services and/or Non-included
Installation Services.
Accepted by:
X
mmni9nl 1
Customer's Signature Date
Page 9 of 11 NO. 2686-222171 Store Copy
Page 10 of 11 No. 2686-222171
Home Improvement Agreement
PLEASE READ THIS
Important additional information regarding Customer's rights may be contained in an attached State Supplement.
Scope: This "Agreement" consists of this page, the following General Terms and Conditions, the Invoice, the State
Supplement if applicable, and any drawings or Change Orders expressly made a part of this Agreement. The Agreement is
between the Customer identified on the Invoice and Home Depot U.S.A., Inc. ("The Home Depot" or "Home Depot"). Any
installation services provided under this Agreement shall be performed by a licensed and insured third party Authorized
Service Provider. The Home Depot does not perform architectural or engineering services, nor does it make structural
changes to dwellings or other structures. The Home Depot and its Authorized Service Provider will perform installation
services in accordance with applicable law.
Pavment Schedule: Payment is required as indicated below. Please initial here to opt to pay the total amount of the sale
now; Customer has the option of paying less as further specified in the State Supplement.
Payment: $ 21949.83 Due in full immediately.
Sales Tax: $ 577 52 If applicable.
Total Amount of Sale: $ 92597_3S Includes all applicable discounts, rebates,and
taxes. Excludes finance charges.*
*Any interest payments or other finance charges will be determined by Customer's separate cardholder or loan agreement, to which The
Home Depot is NOT a party, and will be in addition to Customers payment under this Agreement, Customer is subject to the terms and
conditions of the cardholder or loan agreement, as applicable. No funds should be made payable to Authorized Service Provider;
however, Authorized Service Provider may collect Customers payment(s)made payable to The Home Depot.
Anticipated Delivery/Installation Schedule
Deliver Date: TBD Start Date: 07/25/2011 Finish Date: 08/20/2011
Acceptance and Authorization: Customer authorizes The Home Depot to order and arrange for the delivery of all goods
and services included on the Invoice. Customer further agrees and understands that this Agreement is the entire
agreement between Customer and The Home Depot with regard to said goods and services and supersedes all prior
discussions and agreements, either oral or written relating to said goods and services. This Agreement can not be
assigned or amended except by a writing signed by Customer and The Home Depot, Customer acknowledges and agrees
that Customer has read, understands, voluntarily accepts the terms of and is entitled to and has received a complete copy
of this Agreement at the time Customer signs the Agreement. Do not sign if blank or incomplete.
Electronic Signature: The parties to the Agreement agree that the digital signatures of the parties included in this
Agreement are intended to authenticate this writing and to have the same force and effect as the use of manual signatures.
Customer acknowledges that he or she is the person named on The Home Depot contract number identified on the point of
sale device.
CANCELLATION: CUSTOMER MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR
OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE
THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. Under such circumstances, Customer's
payment(s)will be returned within ten (10) business days after The Home Depot's receipt of Customer's notice.
Accepted bY��
x 07/08/2011
Customer's Signature Date
Authorized Service Provider's Full Business/Trade Name,Address and x _
License No. or No(s).,as applicable: Associate's/Authorized Service Provider's Full Signature
Date
Associate: Please print your salesperson's license number,if applicable.
License No(s).
Authorized Service Provider's Tel. No.
Questions? If The Home Depot store and Authorized Service Provider are unable to answer Customer's questions,
Customer may contact The Home Depot Customer Care Department at 1-800-553-3199 or use the address below.
Home Depot U.S.A.Inc.,2455 Paces Ferry Road,NW,Bldg 5.3,Atlanta,Georgia 30339
312011
Page 10 of 11 No. 2686-222171 Store Copy
Page 11 of 11 NO. 2686-222171
Home Improvement Agreement
General Terms and Conditions
Responsibilities:
The Home Depot: will provide the products identified on the Invoice and make arrangements to have the Authorized Service
Provider perform the installation services in a professional and workmanlike manner. Unless otherwise expressly provided for
herein, Authorized Service Provider will obtain required permits and provide permit numbers if required.
Customer: will identify any property lines, easements, covenants, underground or overhead utility lines, pre-existing physical
or environmental hazards, building code violations or other legal encumbrances that could affect the installation services prior
to the installation. Customer shall keep posted permits on display at all times. Customer is responsible for any delays or
interference caused to installation by Customer or third party under Customer's direction or control.
Changes and Change Orders: Any changes to the installation, including but not limited to changes necessitated by
undisclosed, unidentified or unforeseen conditions on the site, are subject to a written Change Order signed by Customer and
The Home Depot and any additional products or services included in such Change Order will be paid for in full before any
tuch change is made. The Home Depot or Authorized Service Provider has no obligation to attempt to remediate any such
conditions and may immediately discontinue the installation or ask for a Change Order. Please note, The Home Depot or
Authorized Service Provider will not remediate any mold, asbestos and lead-based paint. Neither The Home Depot nor the
Authorized Service Provider is responsible for delays caused by events beyond either party's control including but not limited
to acts of nature, governmental actions, delivery delays or damages caused by third parties, labor strikes, Customer's credit
or financing, or any incorrect information or non-compliance with this Agreement by Customer.
Lien Waiver: State Law Supplements: Home Depot Licenses: If Customer makes all payments as required under this
Agreement, Home Depot hereby waives its right to file a mechanic's and/or materialmen's lien and will protect Customer's
property from such lien filed by any person in connection with goods and/or services provided pursuant to this Agreement.
Additional specific state required Supplements are available at www.homedepot/com/statelawsupplements. License or
Registration Numbers held by or on behalf of Home Depot are available at www.homedepot.com/licensenumbers. State
Supplements and License Numbers are also available at the Special Services Desk in The Home Depot Store.
LIMITED WARRANTY: TO THE EXTENT PERMISSIBLE UNDER APPLICABLE LAW, THE HOME DEPOT WARRANTS
THE WORKMANSHIP OF THE INSTALLATION FOR ONE (1) YEAR FROM ITS COMPLETION DATE. PROVIDED
CUSTOMER NOTIFIES THE HOME DEPOT DURING THE WARRANTY PERIOD, THE HOME DEPOT WILL ARRANGE
FOR REPAIR AT NO CHARGE TO CUSTOMER FOR ANY DEFECTS DUE TO FAULTY WORKMANSHIP. THE HOME
DEPOT'S WARRANTY DOES NOT COVER DAMAGE CAUSED BY ACTS OF GOD, INSTALLATION OR REPAIRS MADE
BY PERSONS OTHER THAN THE HOME DEPOT OR AUTHORIZED SERVICE PROVIDER, ABUSE, MISUSE, NEGLECT,
OR NORMAL WEAR AND TEAR. MERCHANDISE AND MATERIALS ARE COVERED EXCLUSIVELY BY THE
MANUFACTURER'S WARRANTY, IF ANY. THIS LIMITED WARRANTY GIVES CUSTOMER SPECIFIC LEGAL RIGHTS
AND CUSTOMER MAY ALSO HAVE OTHER RIGHTS THAT MAY VARY FROM STATE TO STATE.
WAIVER OF CERTAIN DAMAGES: EACH OF CUSTOMER AND THE HOME DEPOT HEREBY WAIVES ANY CLAIMS
AGAINST THE OTHER FOR LOST USE, LOST PROFIT, LOST REVENUE, INDIRECT, INCIDENTAL OR
CONSEQUENTIAL DAMAGES RELATING TO THE INSTALLATION, THE MATERIALS OR SERVICES OF THE HOME
DEPOT OR OF AUTHORIZED SERVICE PROVIDER OR THIS AGREEMENT. TO THE EXTENT CUSTOMER'S STATE
DOES NOT ALLOW THE EXCLUSION OR LIMITATION OF INCIDENTAL OR CONSEQUENTIAL DAMAGES, THIS
SECTION MAY NOT APPLY.
Termination: If Customer breaches this Agreement or declines a reasonable Change Order request, The Home Depot may
immediately terminate the Agreement without further obligation. In the event of such termination, Customer agrees to pay
The Home Depot the costs 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 DOWN PAYMENT OR
OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH
AMOUNTS.
Acknowledgment: If Customer's purchase includes Countertop installation, Customer acknowledges and agrees that
Customer has received and understands the following additional documentation: (a) Countertop installation: What to Expect;
and (b) Product Specification Sheet. The Home Depot, via third party, offers Extended Protection Plans on some products.
Customer may receive marketing materials on The Home Depot's behalf concerning such Extended Protection Plans.
Home Depot U.S.A.Inc.,2455 Paces Ferry Road,N W..Bldg 6.3,Atlanta,Georgia 30339
3/2011
•Page 11 of 11 NO. 2686-222171 Store Copy
1424
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