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2 HARRISON RD - BUILDING INSPECTION (2) \ The Commonwealth of Massachusetts Board of Building Regulations and Standards CITSAY O xx W Massachusetts State Building Code, 780 CMR Revised Mar 2011 l Building Permit Application To Construct,Repair,Renovate Or Demolish a One or Two Family Dwelling T1us Section For Offwal Use Only (� ) Binding Pernnt Number a .. W t D a Applied zs a6w a dz V � "z �,, :Building Otiicial(PnnfNartie) ., D 'r "..s+SECTI09V.1:SIZE INFORMATION 1.1 Property Addr s• f� �c n 1.2 Assessors Map&Parcel Numbers I I -,^ /-i -%V-� i`o nrn 1.1a Is this an accepted street?yes Ot_ no - Map Number Parcel Number i�o 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) , Frontage(ft) V' 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 Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION2 'VROPElt1 X.OSVNRILSHIPA ,x -` saw 2.1 Owner'of Record: memow Vi'l 101- t-OA Sa�2. th VAA 01Ot7D Name(Print) City,State,ZIP - a San d of 7yS-St,b7. No.and Street Telephone Email Address SECTION 3 DESCRIPTION OF PROPOSED WORK-(eheckall thattapply), , rBriefiescrl struction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) � Alteration(s) ❑ Addition ❑ n ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: tionofPropose Wo ' A A, l l I �e C.�Y' 4 4 t- Win O 0 8 3T X 7k 4L C- crt e$ SECTION 4 ESTIMATED CONS - R[ICILON COST$;„ Estimated Costs: Item Labor and Materials OfSetal-IIse Only v 1.Building $ 13 3 7o- 1-1 13uildmg--Permit Fed.': `Tn, care how'fee is tletemvned: 2.Electrical $ 0 Standard,;,Cityfrown pphcapon ee y .10 Total Project Cos13,(Item 6)x multiplier - x•' a 3.Plumbing $ 2 'Other Fees $ t x x c 4.Mechanical (HVAC) $ .List• ' .x`i t s .. +x '`-• 5.Mechanical (Fire T � 5 Suppression) $ Total All Fees $ '�`' '" +. z f5 Check No Check 4mount ` F Cash Amount .< 4 .: 6.Total Project Cost: $ �37 O ❑Paid'in Full* ❑Outstanding Balance Due SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) cj q License Number Expiration Date Name of CSL Holder Qa `, , AO-1-CS r\ List CSL Type(see below) No.and Street Type Description YV% P 1 7 p U Unrestricted uildin s up to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding r r SF Solid Fuel Burning Appliances 4 a►`b 1 5 a�� I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) Hb Mt be ioZs ►abed 3 � 3-i(o HIC Registration Number Expiration Date HIC Com any ame or HIC Regigpr t Name, 9b� eS4oh ur'n IK-e, No.and Street Email address Cl,rewsb�r� Mg 0w S 4u1 694 �`f3q City/Town, State ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AP PIDAVIT(M.G.L a,152.§ 25G(6)) Workers Compensation Insurance affidavit must be c9ppleted and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuan of the building permit. Signed Affidavit Attached? Yes ..........V No...........❑ SECTION 7a:OWNER AUTHORIZATION FTO BE COMPLETED WHEN OWNER'S AGENT„OR CONTRACTOR APPLIES FO$>3UILDING PERMIT I,as Owner of the subject property,hereby authorize I'611,1.- A�"'V•" ` to act on my behalf,in all matters relative to work authorized by this building liermit application. Print Owner's Name(Electronic Signature) Date SECTION 76:OWNER'OIi 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 a lication is true and ccurate to th best of my knowledge and understanding. r'10.rK .�/In)X _ g 2 z r�V Print Owner's or Authorized Agent's Name( lectronic S! ature) - Date NOTES• 1. 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 ++tivw.mass.eov/oca Information on the Construction Supervisor License can be found at M2MAMI ss.>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" l%r :> '?lU�•az%142 o/v / �i�d; J •��lG/JG' i• Office of Co surper Affairs and Business Regulation 3® fl''artc Plaza - Suite it�c 5170 Boston, Massachusetts 0.2116 fl ome Inng7roVe1K4 djA.;gontractor Registration Registration: 126893 -••r:d .7:•+j?; :;.r%i.i .' r Type: Supplement Lard Expiration: 8/3/2016 THD AT HOM E SERVICES, NC. MARK NIADNA• 2690 CUMBERLAND PARKWAY SUITE-3 ATLANTA, GA 30339 -.___.........._... ,_........ _.__.__...__.,__.........:.. . . . Updato Address and return card.Mark reason for change. scA i c; 2UM•05111 Address ❑ Renewal [' Employment Lost Card I �::�/r'YPrvnuroirnrorr(//r�(?•l�n.:�rrr/rr�r./Li ' •— office of Consumer Affairs&Rusinem Reguladon License or registration valid for individul use only 11. ' . i.' before the eupiration date. if found return to: OME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation �a. Registratlpp:...126693-. Type 101°ark Plaza-Suite 5170 " off Eupiratfon;;,'6/31201.6..; Supplement Card Boston,NSA 02116 THD AT HOME SERy.IQE$;:INC: : .. THE HOME DEPOT,AT,:Ih?ME SERVICES - MARK NIADNA ?:` 2690 CUMBERLAND PARKWAYS GA 30339 Uadersccrclnry I of valid without signature . I i j f�l Massachusetts-OepaRment of public Safety �J Board of Building Regulations and Standards Construction supervisor Specialty License:CSS`4MM*N ROBERTPOCZOJOt 172"AL6RS Salem MA otmoL� _ +I it, Expiration - Commissioner O�JOti/20f8 - - - - The Commonwealth of Massachaneus Depiartnsent of Industrial Accidents Offke of Invesdga&ns t 600 Waskington Sheet a Boston,MA 02111 www massgov/dia i Workers' Compensation Insuftnce Affidavit: Boadera/Contractors/Electrecisas(Plctmbers_ Please Print Legibly ___. —ADnlicant Information__ . .-- v_ _ Nance(Business/Orgmirationnndividual): Y—Ome, Adaress:_ qog 6 o s .N I tlr-Aso/� G[ty/State/Zip: . S v - o/SyS . Phone#: ros- Are you an employee?Check the a Type of project 1 Yappropriate box: p J (required): 1.❑ I am a employer with 4. ®I am a general contractor and I _.employees(full and/or part-time).# have hired the sub-contractors 6. ❑iJew construction 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 area 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-FXIOtherI W-1'e+lf •MY applicant Wet checks box#1 must also fill out the section below showing their workers'compaintion policy mtortmtiun. t Ifomeowners who submit this a8'idevit indicating they she doing all work and Wen hire outside conbactets must submit a new affidavit indicating such, tConirectors that cheek this box must attached aoadditional sheatshowmg the name of the subs namuctars and their workers,camp.policy intbmation. I dun an employer that is provMing workers'cwnpensadon insurancefor my employees. Below Is the po&yand Job site Infornrgtlon. �� /'/ .5 /rrG Insurance Company Name: A�1 f7 �$ co , r/ r� 2 q t Policy#or Self-ins.Lic.#: JwI C- O / / d y ( 3 Expiration Date: 3 _� 01,916 Job Site Address: T r r uv� -[ 11] f City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date} Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a c fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250:00 a day against the violator. Be advised dw a copy of this statement may be forwarded to the!)Duce of Investigations of the DIA for insurance coverage verification. I do hereby certify anVr=�pah&ra#&dpw#WaofpCrJxjy that the lttforntallon provided ebove is true and torrent Si L Phone#: �- Official we o)*. Do not write or this area,to be competed by city or town o clat i City or Town: Permit/License# ' Issuing Authority(circle one): S 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: A R CERTIFICATE OF LIABILITY INSURANCE °o0224ao+5°� ' 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 CONSTITUTEA 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 t certificate holder in lieu of such endorsement(s). - _ - t PRODUCER CONTACT _.. ".'.."_MARSH USA,INC.'"".._- ;SERVICES, ..w,�.._.-..,,-.- �---_- ,..._.-NAME:-..,... - TWO ALLIANCE CENTER PHONE FAX 3560 LENOX ROAD,SUITE 2400 -k7Nl AK No i ATLANTA,GA 30326 ADDRESS: - INSURERS AFFORDING COVERAGE NAICE 100492-HOm80.GAW-iS16 . :. INSURER A:Steadfast lnsuznce Company 26337..INSURED INSURERB:Zurich Amaimn Insurance Co 16535 THD AT-HOME SERVICES,INC.DBA THE HOME DEPOT AT-HOME INSURER C:New Hampshire Ins Co 23841 2590 CUMBERLAND PARKWAY,SUITE 30D - - -- Illinois National lnsurenieC n -- ATLANTA,GA 30M - - _ IN56ien u: � y 23817 INSURER E: INSURER F: i COVERAGES CERTIFICATE NUMBER: . -. ATL-=24268509 - 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-CONDITON OF ANYCONTRAC7 bR OTHER DOCUMENT MATH RESPECT TO WHICH THIS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AM 9w POLICY EFF POLICY UP LTR TYPE OF INSURANCE POLICY NUMBER MMNDNYYY) rMNMxDovYYi LIMITS A. GENERAL LIABILITY GL04867714-05 - - 03/012015 034)V2016 EACHOCCURRENCE $ 9.000;000 X COMMERCIALGENERAL LIABILITY PREMISES Ea oaun ,, $ 1.000.000 e CLAIMS-MADE OCCUR LIMITS OF POLICY XS MED UP tAnY one person) E EXCLUDED OF SIR.$1M PER OCC PERSONALS ADV INJURY $ $000.000 GENERAL AGGREGATE E 9,000.000 GEN-L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ s.D3D,o°D 1 X POLICY P o- LOC $ B AUTOMOBILE LIABILITY BAP 2936863-12 03A012015 03/012016COMBINED a B Neit I �DSINGLE LIMIT E a $ X ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG AUTOS AUTOS BODILY INJURY(Per accident) $ { HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS Fare Ider4 E I $ k UMBRELLA LIAR OCCUR EACH OCCURRENCE g EXCESS LIAR CLAIMS-MADE AGGREGATE - S DED RETENTION$ $ t ----C -WORNERSCOMPENSATOw— WC017731'493-(A0S)—" 03/0l/2C1T5- 03/012016 WC STATU- OTH --- -- ] AND EMPLOYERS'LIABWTY T T 10�000 - C ANY PROPRIETORIPARTNERIEXECUTNE YIN WC017731495(AK,NY,NH,NJ,VT) 03N12D15 03/012016 EL EACH OCCIDENT E " D OFFICERIMEMBER EXCLUDED? NIA p (Mandatory In NH) WC017731494(FL) ONI2015 031012016 E.L.DISEASE-EA EMPLOYE S 1.000,WD Nt daseONunder Conilnued on Additional Page St DESCRIPTION OF OPERATIONS below 9 E.L.DISEASE POLICYLIMIT $ 1'�'� 4 I DESCRI"DN OF OPERATIONS I LOCATW NS I V HCLES(ANaeh ACORD 101,AddNlonal Remarks SelRdale,X rneR eP]001B nqulmd) t EVIDENCE OF INSURANCE 6 y� 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. i ATLANTA,GA 3M39 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. - ManashiMukhedee '- r ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD K e - Simonton Windows -- 6500 VantagePointe - NrxC - Double-Hung Vinyl 1/8"Glass Argon Low-E No LaminatedGlass - No Grids e - a _ *asx FsresrtaiFor . -Ventana dedoble guillotine Vinilo. 3,18.mm Vidrio:.Argon-'Low-E Sin-_Rabbi aim vidrio llaminado_:Sin rejillas E - _-_.._. CPD SBP-A-44-21042-00001. j 0745 DH - - - a ENERGY PERFORMANCE RATINGS EVALUACION DE RENDIMIENTO ENERGETICO - 6 - U-Factor Solar Heat Gain Coefficient 3. a Faderll naef:imto:Ganancia d:Energia Solar j 0.29 1 :65 0.27 (V.Sf Pl lMetrku191) - - ADDITIONAL PERFORMANCE RATINGS EVALUACION SUPLEMENTARIA DE RENDIMIENTO - a Visible transmittance 0.50 a - ManulaciurerSli Mates that those ratio conform to Iicable NFRC rocedures for cars, whole rodent perform e P 95 Pp` P g p p e.NFRC rwarraare dalermtned par eflxed eel oten�ronmenlal conditions and aspe�;ifs product s¢e_NFRC does not recommend any product and does nor warrant[no d suilabi11,of any protlucl for any specific use.Consult manufacturer's rderotor;for other product padormame lnf.,.allon.vmw_nirc a, Este latricanle sepula quavalwas cu mplen ccn Jos procemmientes aplkales da NFRC pan,detornimai el rendmiente local del pmducto.Los vaii - Isados porNFRO son delerm'mados par un conlunle Go do condccncs anther:tales y to to m and de Pm don]espesM:o_NFRC no rexermenda pas ningun product y no garanlha quo el product sea adeouadd pare on tna aspaoYro.Corn into on at lallelo del labrcsnte pare el use a,,a,gdo de esle product wow.df,.,g Unit qualifies for ENERGY i STAR®region(s): Northern, North Central,South Central, Southern. d 1 STC:ZS DP:+25/-25 IND:Rein 00/31ass ProSolar/H-LC25 Tested Size:48"x 80" I Florida Product Approval: FL5167 E In In E Applicable Test Standard(s): ANSI/AAMA/NVJWDA 101A.S.2-97,AAMANVDMA/CSA 101A.S.2/A440-05,AAMAANDMA/CSA 101A.S.2/A440-08, A440S1-09 Canadian Suppl 6 8971158/03 g0465 HS Gerlach 6860223 - Keep this Jebel for possible ENERGY STAR@ rebates.To learn more visit www energyelargov. g Guarde ese eliqueta posibtes reembolsos ENERGY STAR@ Pare conecer rods acema de esto,visile www.energyelar.gov. I a 8 IIj { ' _ nOMKIMPRnvRMKNyr•nN'rentrr Ir1.ItANK Igsnu•ones C] � Skid.Fumished and Invlalled by 11/N11N11 N*rtWt Rtwhm NmihA lhndh IMlel r'I/_�� 1111)At-Ifrmle ServicO,Inc. iVIVII The 11ume Depot Aldlranc Services RfwW41 Ninul*rrt Al wad AA 4IIX Rrnam Turnpike.Unit 1.Shrewsbury.MA O1545 Toll Free 877-903-3768 Pr,lend lit N75.1.fANMaI;MR lie N f_'a243o:kl Crnl.Lie* IW27 �/�J (•y.< '` t 9'I.Ic*111 `.4050NI:MA Monte Crntrcm a ¢keg.*126kn3 IIIeI*11*ohm AlhliNMl SJL �� F'J*-� /`�. 3 ._,,.,.Jj'1L -'n•A._.{vv'r.--G--�` —! Chy Stifle %aP Paolo wNifa %'fork Main l Moore Matter: Cell Phrme: nrmw Addtoa; III Piu,-P,tA Gran Gnfeilndlm Addic.ti � ...._.. _._._�.__._._ City Stale Zip r,,)Nnd Addtaa Ion rr4'rlve ptolM I cunnnnnirnhms find I lutur IIvpA ulxlntes): I'l 10/NO Of wl<II In im elve fury anu kr•Itug emniN lmoi'llie l k oac Ucpra I'tr/J1}(I hlffrtrnailmti l lnlirt<ipnrll l"Cood mer'1•lire uwllerc it life property limuLd at the utx,vc installation addrera,afrrm In buy Ind I IIN Ar iGxnr t,,Fvh ee, ha_ 1"I PIP Minor I/PINI1'1 ngfvv4 IN hirvish,deliver laid:IttMgc PIN the Insiallaw ro ri nxtallation•)of Ntl uamarinty flew IiI'A not Ilir Igdow mud an the IvIilenccd Spec Shrell s). all of which are incorpr*aloil into lit is Contract by tin I Iffewtn(" ulnrp will,Nay Npptienite Shuc Supplement and Puymc il.Summary nttachcd herd,and any Change Orders larllec'tively. "i,imh*r 1'q I ,IMr tli N+arens r.r......i Sec Sheets *: Prot eet Amount i ee�� 1 nMm N: nk xgrn¢ IJ SidioY rI windo w. Q In.ulntiun r� 2 �11�1/tr yy�r/ Ilt7nnrr</l rrvwry [,l)nnY 1pxx< I] ,._a.�� I��j� $ - 1`lkru lu4 rI!+Idinp©lNindrwv Q 6lvullrl uhn $ 1_�/irulrre/1'avrw I�laery llrxns [��_. nkru4inpQtiaaugQ WifnWwer•� lo<ulnliin $ rThdlet</(omen rhntry Unrm[:I -,._�_ -QkfeAlnk Q4tding Q tVTnNw< �I r.ugnian 1"Irhxter<717rvrr. [-]I'Illy Urxxf (]._.,_ Is MMNnrlrr le,r Agw.N iv,ArM Awn"Mrap,NlPv rihOn rA....rlearrxl. Total Contract Amount Motion,Motion, M M Prmlwwn inn e ArtN,W Moe Ihml omr-lMrdxN Ile('oearwi Amrllm. Cuvtrerk•r,npferN II,011 ifnll"Ataiely alum complelitm of life wink for each Product.Cusirmrer will execute a Completion Certificate Qmr ire rrnli Prlxhad in de0nud by Lin individted Spec Shreli and pay tiny balance due. As applicable,each Customer under this Ct*drwf egrtes Into)trimly mul sovcrNlly olliigldral and liable br'.rcundcr. 'rtul f Irene f${aN receives die I10,1 ur issue N Change Order rot Icrminulc This Crmtmct ry tiny individual Product(s)included herein,at on 11W Ietlln•if'1'be Ilrmre UcINd to its uulhiNiyed xxvtcc provider dclartanes ihm it cannot perform its ohligations due to a structural 1444"',will,the ht4nr,envareunemnl hmnud<such as mold. tishesuw ur lead prim.nlher safety concerns,pricing errors or because week toi pnred h,rf4npluic Om 04i was ma included in the Ctallract. 1'edrneM.�!iummnrYi 'I he 11Irynlcal Sunonar , N_.'Q ;, � �l, included as purl of this Contract, sers forth the total CrMtraef*aaaM and I41ymrnla required fro thr drlarsits and linul payments by Irnaluct(as applicable). NOTICK TO Cl ISI.OMER Von#art tnlfkli lei*emotrilefely fllled-ho Copy fd fife Contract Lit the.time you sign. On not sign a Completion Certificate forte: Ilse,Ie roe f'mmplethm(.'erUlicate for enwh tinted Product as defined by Individual Stir Sheets)befure work on that Product On rrmi(Atit. In 1M"on if lamin*lime of olds C.o frfirt,Cinlotrwr agrees it.tiny'rhe 110me Uepot the costs of materials.Intl r,expemyes *red wtv1,is prrrsidrd toy'Ilw Ilbina Itrl*d for Alit hurlxed Service Provider Il roigh the little or terminuthor, plus any other .noo nis<rI for its In this AgrermPnl err allowed under applicable law. TGIF,IIOMK DEW)'r MAY win 111OLO AN1O1'NTS IIWF'It 'IO 'flip• 110NI: 10110T PROM TJ IF, DEPOSIT PAYMENT OR fil'IIER PAYMENTS MADE, WITHOUT IdA91TIM;YYIV,Ilf1NK IrP:INYf'%fY111h:R RP:MV,OIMN FOR RKCOVKRY OPSUCII AMOUNTS. A4e(frinnet and Afdhuyltuilipq; CoMo,oner aerecs findondcnmands Ihat this Agrterirnl is the enure agreement between Customer 011 ,e I�xil.r1•a wn1,uh,nrl In the 15re11,04 mid In.etatbairm services find supersedes fill prior discussimts Lind agreements,either r*At r* wFolm".rehurog to,said Pnghafs mod Inshdlnlitdl.'I'his Agreement cannot by assigned or amended caeepl by a wntutg signed by Clnrrxfrr a frl'i f,c I hnnr Urpf .*,Pail....., urkri wledycn and agrees Phut Cuspnncr has rend,understands,voluntarily accepts the team rat arrd l,a<Ireeiveal a ogry of Ibis Awermcnt. Art tpis : >� `* ulrmllied ly: Ca<fr*nei'•Sr$ralura Ulna 5;.�.... ohm's/}'i);nntt • Date ... Telephimc No. l�g�>_S IQ—q /egs� Cvel"'wWc kiynalure Pate Soles Consultant License Not. lV,ANCIAJSIIIN; CILNTOMRR MAV CANCEL TIII.S Im�INiaamn ALRVV:MVNT W1'fl1O1r1'PF.NAI.TY OR I/RLICATION RY OV•IdVV,RINI; WRITI`VN Nt YI'If:K'I'O'Ito P; IIOMK IrVWYI RV AIll"Y"JIT ON 'I11V. '1'111RU RIISINNSS IPAV AIIMR .411;NIs11; 'HUS AGREPMP.NT, TOP, " vi-A'fv kI;PPf,vMV,Nf ATI'M'IIKO IIERKTO I II*rf 41441 A FORM 'ill 11811, IV ONE IN eVVIgVd'ALLV 1'RV„4or RINPdI NY LAW IN 1.L4fOMV,N'N 4'fA'l l;,