10 HAZEL ST - BUILDING INSPECTION (3) Cam# �3S`1 t�
'�E'C�tVfD
The Commonwealth of Massac use s '
h� Department ofP1tycyVL e /� 1
1. 30
Massachusetts State Builclmg Co^or (7V Mf'1j
Building Permit Application for any Building other than a One-or Two-Family Dwelling
M (This Section For Official Use Only)
1
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
No.and Street City/Town Zip Code Name of Building(if applicable)
�}• SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Changt of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work:
e
lwc
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING LNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels) &Area Per Floor(sq.ft.)
Total Area(sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ F B: Business ❑ E: Educational ❑
F: Factor F-1 ❑ F2❑ I H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1.❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3 Cl R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ ILIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal Trench Permit: Debris Removal:
Licensed Disposal Site ❑
Public❑ Check if outside Flood Zone❑ Indicate municipal ❑ A trench will not be P
required ❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: MA I Ii,<< is�OOl,ml 'ion l: i F 1"mc's :
Not Applicable❑ Is Structure within airport approach area? is their review completed?
or Consent to Build enclosed ❑ Yes ❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
L� t-t
( t
�; QU (���Q/�_
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Nai�(PHAT)' � No.and Street City/Town Zip
Property Owner Contact Information:
b.,,hto,- 1v17=e23q-fag7 -
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
I�f�G�r� � �l Al7T�
am Stre- Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit 1221ication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1.
10.1 Registered Professional Responsible for Construction Control
��WP L17-35y/-y9`f�ri(.6 d•c:.halene� foie. 1
N,a�me!(Rogistran Telephone No e-mail address jpfvles, Registration Number
Street Addre'y GCy/To tate Zip Discipline Expir ion Date
10.2 General Contractor
/I [ice! � (fn
Company Nam
�r,v111 � 711 F7
Name oaf Persosible for Construction License No. and Type if Applicable
Street Address City/T wn State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:iVORKERs COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? - Yes 0 No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ , appropriate municipal factor)_$
3.Plumbing $ /
4.Mechanical (HVAC) $ / Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereb attest under the at and enalties of perjury that all of the information contained in this
application is true and accurate to bes of my n e e a understanding.
6�r� 3�Y oyY/O/
Please print and sign name Title Telephone No. Date
�7.
Street Address City/Town State Zip
Zip
/]
Municipal Inspector to fill out this section upon application approval: "Wpk �l
Name Date
April 4, 2o16
To Whom It May Concern,
This letter is in regards to the replacement of the basement door for
io Hazel Street in Salem, Mass. We authorize and approve the
replacement of this basement door.
Thank you, 9�
Gina Mannion
io Hazel Street Condo Association
rm..
The Gmnnunmeulth uf,1/as.crrchusett.c
. 4' Department oj'/nrlush•jnl Arcirlerttc
{r I Congress 6n•eet, Smite lllll
Boston. AIA 02114-201 i
www.mrt.s.y.go o/rlia
Vk orkers'Compensation I its,orluice AffidaAiL Builders/Contractors/EI cctricians/1'IonI hers.
l'0 It FILE:I1 WI III I I I E PERM II"rING At 1110It I11.
Applicant Information �Q� ] Please Print Lc•aihly
NantcIRueinrs4lrc:winaion'Indiridu;dl: r 7oha�fl WA'C�1(7
Address:_ ).a TULFKIS (`�•
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= �I:m.1h It va I mi ell l+e loon nlr ell 1. I nxlua all tt rknw:lr I.nc. Itrill _ .
"l'm IIni'llfnnll 1.rc lS rilbrl lnn to YkUF r11.R,dlInll insumn(toI'm' Sol, I I.� 1:1-1II al Cl,:lll,t,r;Idlhllr9l.s
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.1 np6„r.,. II Ihr soh".nnr:n ierx haler rnq,lorres.Ihry uw>I pmcidr Ih%ir avu kiln'cnnlp.pilule numhrr.
/ant an emplace r that is prvmidin,;Yorkers'(•nrnpencation iaruranre lip'n{i'enrphrrers. Rl,/un•is the polit_r and job sill,
in f artrsaion.
In urul�c Cumpam' Name: CQ pli _Chh =nSURUkQ
Com�+1�
— �9m— .-- -— — — —
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— � Lcpiralion Data. 1,. 1?q.1�
lob Site Address: 10 ",�.�` - l II\,'Sl:ud'/ip:_ 5AIr2(t11 /-
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\ttach a cop%of the workers' compensalion policy declaration page Ishowim,the polio nunther and expiration ([:Ile).
I'CrilnrC to sccmc cov'ciagc ;is required under N101_ c. 152.52iA is a criminal violation punishnblc by aline up IT,SI.,;00,0 l
and ,Ir nnc-%car inlprisunmcnl, ac well as cieil penalties in the lone of a STOP WORK ORDI'R mid it Ilne i,t up to S--210.00 a
day.r,Tina the violator. A copv of this suneloent may be lor%nrded to the Office of hI%esll,rations Ill'tile DIA far iusunmce
Ch%cSa!1C %crilication_
/du her'ehr ecni(i'under the pains unn�d prnmtlies al perjarp that the ialormotina provided ahmar is trill,and correct.
\i_nJture_� �.y�-yam Dale:
Plull,c 17J- 53-2- D342.
official use an(r. Do not nv'ite in this area, to he romp/eted hr rill•al,linen allicinl.
Cit) or Town: Pe rnl i Ul..icense k
Issuim.,Aulhority(circle any):
:d 1. Board of Ife Ut 2. Building Department 3.Cih'/Town Clerk J. FIlecn'ic:d Inspector 5. Plumbin;, Inspector
0. Other
Conlac•t Person: Phonc tt:
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Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License;CS-071187 ,
Construction Supervisor '
✓Y I
' 1 RONALDE WACfihiN
12 TUCKERS CT,"3RDVC 'r 'r
PEABODY MA 01960 4a q�
b
tin lam-- Expiratlon: ;
Commissioner 0810412017
i
I of 1 03/23/2016 07:28 AM
1.4
Office of Consumer Affairs afid Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 148688
Type: Supplement Card
LOWE'S HOMES CENTERS LLC. Expiration: 10/18/2017
RICHARD CHALONE
136 TURNPIKE RD. SUITE 100 -
SOUTHBOROUGH, MA 01772
Update Address and return card Alark reason for change.
Scn a zm.i nc:1, Address Renewal Employment Lost Card
1 bf ec of Consumer Affairs A Business Regulation License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
'tt1.r'-,',...- - Office of Consumur Affairs and Business Regulation
Registration: 148688 - Type: 10 Park Plaza-Suite 5170
`- Expiration: 10/18/2017 Supplement Card Boston,NIA 02116
LOWE'S HOMES CENTERS LLC.
RICHARD CHALONE -
1000 LOWES BLVD
MOORESVILLE. NC 28117 Dnderserretary Not valid wilho t signature
CERTIFICATE OF LIABILITY INSURANCE DATE fMMJDD/YYVYI
ITMIS.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. CERTIFICATE
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(iss)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to
the certificate holder In lieu of such endorsements.
PRODUCER CONTACT
NAME:
PA I RICK J WOODS INS:AOCY PHONE FAX
40 MAIN$1 RF,I;:I DVC,No,Exf) (A/C,No):
EMAIL
PII.AIIODY, NlA 01960 ADDRESS:
71-a1 Y INSURERS)AFFORDING COVERAGE NAIL#
INSURED INSURER A: AC ANIERICAN INSURANCE CONII';ANY
WACIJLIN. RONALD DBA RONCO CONSIRUCI'[ON INSURER B:
INSURER C:
INSURER D:
12'11IC'KFItS C"I
INSURER E:
PEABODY.NIA 01900
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIODINDICATED. 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.
INSR ADD SUB POLICY EFF DATE POLICY EXP DATE
LTR TYPE OF INSURANCE L R POLICY NUMBER (MM10D1Y'IYY) IMMIDDIWW) LIMITS
GENERAL LIABILITY EACH OCCURRENCE S
Ll COMMERCIAL GENERAL LIABILITY
CLAIMS MADE EI OCCUR. PREMISES S( RENTED S
(Ea occurrence)
MEO EXP(Any one person) S
PERSONAL 8 Ai INJURY S
GENT AGGREGATE LIMIT APPLIES PER'
GENERAL AGGREGATE $
POLICY 0 PROJECT a LOC PRODUCTS-COMPIOP AGG $
AUTOMOBILE LIABILITY COMBINED SINGLE IS
ANY AUTO LIMIT(Ea amioent)
ALL OWNED AUTOS BODILY INJURY S
SCHEDULE AUTOS (Per person)
HIRED AUTOS BODILY INJURY $
(Per acaitlent)
NON-OWNED AUTOS
PROPERTY DAMAGE 6
(Per Accident)
UMBRELLA LIAR OCCUR EACH OCCURRENCE ,$
EXCESS LIAR CLAIMS-MADE AGGREGATE $
DEDUCTIBLE 'S
RETENTION S is
A WORKER'S COMPENSATION AND X OAOSTATUTCRY OTHERI
EMPLOYER'S LIABILITY YIN UB-4805PO12-15 10/29/2015 10/29/2016 LIMITS
ANY PROPERITORIPARTNERIEXECUnvE OFFICERIMEMBER E>!CLUDF:D'+ E.NIA L.EACH ACCIDENT $ 100.000
(Mandmory In Ni E.L.DISEASE-EA EMPLOYEE S 100.000
It yes,desutte u,wer EL DISEASE-PGLICV LIMITS 500.000
DESCRIPDON OF OPENAIIONS below
DESCRIPTION OF OPERATIONSILOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS
1111S 121"PLACES ANYPRI0I4 CER I IIIC\'FE ISSUID'10 TIF CIA]IFIC:A 11:I OLDCR JI`I.CIING W'ORKIFRS IONIP COVI=.R:AOF
IT If:IN'SURED',C MA\VORKERS COMP I.NSA I ION POI_IC\ AND 19:S LIMITED 0"011 P.Sl A'ITS I NDORSKN IFN'T AU"II IORI%I!q 1111 PA Y%II'N r OF ItIIm:n P;FOR CI AIMS
.MADE BY lOF INSUREDS NIA 1'..A111OA EIi9IN S'I A I FS tillIFIR I1I:AN NIA. NO:Atli IURIZAIION IS(it%LN TU PAN CL.-AIMS FOR HI.NL"1'I IS IN YFAILc 0'11fER
11I AN h1A If Fill,INSI!RED HIRES OR HAS INKED F AII'I 0)1 IS Oil ISIDEOF%I:A. 'I HIS VOI.ICI DOES NO I NO( A'IN (OVf RAUk FOR A.N')'S I I'1'01'HEIL'11 IAN MA,
'I III \VORKIU(S'CUNIPI NSA'IION POLK'Y DOES N(y PRO\IUL CO\ERAGE I'OR\VACHLIN.RONALD,
CERTIFICATE HOLDER CANCELLATION
LOWI.'S COMPANIES IN( SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
IS INSIJKANC�Ii I'O BOX I I 1 I BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL B DELI ,.D
IN ACCORDANCE WITH THE POLICY PROV
AUTHORIZED REPRESENTATIVE
WILhI BORO.NC 28656
ACORD 25(2010J05) The ACORD name and logo are registered marks of ACORD 1988.2010 ACORD CORP R rights rosorvod.
STORE COPY
INSTALLATION SERVICES CUSTOMER CONTRACT- MWORK- INT/EXT/PATIO DOOR
LOWE'S OF DANVERS, MA., STORE# 1094 STORE PHONE: (978)646-9099
1 113 153ANDOVER STREET SALESPERSON: EDWIN VELAZQUEZ
DANVERS, MA 01923-1450 SALESPERSON ID:794346
Document Print Date:03/17/2016
This is only a Quote for the merchandise and services printed below. This becomes an agreement upon payment and issuance of a Lowe's receipt, upon which the entire agree-
ment, including the specifically completed pages of this document, the Terms and Conditions included with this document, the applicable portion(s) of Lowe's receipt, and any
other addenda or attachments hereto,shall be referred to herein as this"Contract."
PLEASE READ THIS ENTIRE DOCUMENT INCLUDING THE "TERMS AND CONDITIONS BEFORE SIGNING
Lowe's Registration or Contractor License Number/Lowe's Contractor Name
Lowe's Home Centers, LLC's MA HIC NO.: 148688 Lowe's Home Centers, LLC's FEIN: 56.0748358
Customer Name Home Phone
S JOHN MANNION 617-259-8297
O Customer Address Other Phone
10 HAZEL ST, APT 1
L City State/Province Zip/Postal Code
D SALEM MA 01970
:• Installation Address
T 10 HAZEL ST APT 1
0 Installation City Installation State/Province Installation Zip/Postal Code
SALEM MA 01970
MERCHANDISE AND INSTALLATION SUMMARY
MERCHANDISE SUMMARY
76804 : S100 : SOS : SOS THERMA TRU SMOOTH STAR : QUOTE#16120600 : REEB MILLWORK OF NEW ENGLAND - QTY 1
44928 : 690T 26D CP CODE K6 : STK : KW SC COMBO SGL TYLO : KW SC COMBO SGL TYLO : KWIKSET- QTY 1
47209: LW012A : STK : GE SIL I ALL PURP CLEAR 10.1-OZ : 10.1-OZ CLEAR SILICONE WINDOW AND DOOR CAULK : MOMENTIVE PERFORMANCE
MATERIAL- QTY 2
131207 : 131207 : STK : 1-8-16 PRIMED PINE : 1-8-16 PRIMED PINE : IRVING FOREST PRODUCTS (MAINE) - QTY 2
Materials Price $ 679.2
Store 1094 Project No. 467836961 for JOHN MANN ION Page 1 of 8
STORE COPY
INSTALLATION DESCRIPTION
Stock or SOS : Stock Door Type : Exterior
Select Location : Back Door Select New Door : Single Pre-hung
Hardwood(Mahogany or Oak) Door : No Side Lights or Transoms : No
Hidden Damage Description : None Number of additional holes bored for accessories : None
Install Specialized Mortise Hardware : No Install Storm Door: No
Total Linear Feet of Custom Trim to be Installed : 0 Deliver Door : Yes
Customer Understands Scope of the Project : Yes Permit Required : No
Additional Miles Traveled over 20 : 0 Bring Up To Code Description : None
Local Disposal Fee : None Describe Other Work Needed : custom install to cement stone foundation
Other Work Charge : Yes Comments : basement entry door
Lead Safe Practices : No
Labor Charges $ 715.0
Detail Deduction
Additional Specifications:
Notation: Lowe's will not make structural modifications, paint or stain or remove/reinstall security system equipment. Customer is responsible to advise if prop-
erty is governed by Historic District Regulations.
Additional Specifications:Federal law requires Lowe's to provide you with the pamphlet Renovate Right: Important Lead Hazard Information for Families,
Child Care Providers and Schools. By signing this Contract, Customer acknowledges having received a copy of this pamphlet before work began informing
Customer of the potential risk of the lead hazard exposure from renovation activity to be performed in Customer's dwelling unit.
PHOTO RELEASE: Customer grants to Lowe's and Lowe's employees and independent contractors the right to take photograghs of the Premises where In-
stallation Services will be performed and all work performed at the Premises related to this Contract, and irrevocably grants to Lowe's all right, title, interest in
and to the photographs for use in all markets and media, worldwide, in perpetuity. Customer authorizes Lowe's to copyright, use and publish the photographs in
print and/or electronically, and agrees that Lowe's may use such photographs for any lawful purpose, including, but not limited to, marketing, advertising, publi-
city, illustration, training and Web content. By initialing here, Customer agrees to the foregoing. [Customer to initial to the left].
NOTICE TO CUSTOMER-PRICE CALCULATIONS: In order to properly perform the installation of certain Goods, the Contract Price may include more Goods
than actually will be installed based on the measured square footage of the Project Area. As a result, the parties agree that the lump-sum Price stated in this
Contract is calculated upon both the value of the estimated Goods required to fulfill the Contract (including waste), which may exceed the actual square footage
of the Project Area, and the labor which may be estimated based on the amount of Goods required to fulfill the contract (including waste). By signing this Con-
tract below, Customer acknowledges receipt of this notice and agrees and understands that the Price includes these costs which may not be refunded once the
Installation Services are performed..
Store 1094 Project No. 467836961 for JOHN MANNION Page 2 of 8
STORE COPY
TOTAL CHARGES OF ALL MERCHANDISE AND SERVICES 'where applicable
SUB-TOTAL $ 1359.2
'TAX $ 0.0
DELIVERY $ 0.0
ORDER TOTAL $ 1359.2
BALANCE DUE
Work is to commence upon reasonable availablity of Contractor which is anticipated to be (fill in date].
Estimated completion date is [fill in date].
NOTICE TO CUSTOMER
All items listed in this contract and specification sheet(s) are to be installed under conditions agreed upon at time of purchase and at the price appearing
on this contract form. This assumes sound existing substructures, superstructure and points of attachments. Extra labor or material incident to installation
necessitated by defective substructures, superstructure, points of attachment, or the moving of fixtures or appliances to be billed at extra cost to custom-
er.
IF THE CONTRACT TOTAL IS $1 000 00 OR LESS Customer must P>y in full
COMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS $1 000 00•
[_] Customer to Pay in Full; OR
(_] Customer to use the following payment schedule:
(1) Deposit of $ to be paid upon signing contract. Any deposit collected at the time this Contract is signed will not exceed one-third (1/3)
of the contract price; and
(2) Payment of $ to be collected upon or after the commencement of work. I/We authorize Lowe's to do one of the following (check ap-
propriate box below):
[_1 Charge my/our credit card for the amount of the payment indicated above upon or after the commencement of work; or
[_] Deposit my/our check for the amount of the payment indicated above anytime upon or after the commencement of work; and
(3) Final payment of $100.00, to be paid upon completion of the installation to both parties' satisfaction.
.Store 1094 Project No. 467836961 for JOHN MANNION Page 3 of 8
STORE COPY
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND CONDITIONS CON-
TAINED IN THIS CONTRACT AND WHICH FOLLOW THE SIGNATURE PAGE(s). BY SIGNING BELOW, YOU ARE ACKNOWLEDGING THAT YOU
HAVE READ, UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH IN THIS CONTRACT. YOU ARE ENTITLED TO A COPY
OF THIS CONTRACT AT THE TIME OF SIGNATURE.
NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L. c 142A
LOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CON-
TRACT, THAT LOWE'S MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRET-
ARY OF THE EXf'3EECC�WIAVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUB-
MIT TO SUCH A TIONI'AS P VIDED IN M.G.L. c.142A.BY:C� O, Date: 3— I ! — ( /�P
L s Home ters L
By:/ Date:
Ow r I
By: Date:
Co-owner or Witness
THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION
INITIATED BY I OWE'S PURSUANT TOM L c 142A THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION
EVEN WHERE THE SECTION ABOVE IS NOT SEPERATELY SIGNED BY THE PARTIES
WITNESS OUR HAND(S) AND SEAL(S) BELOW THIS 17 DAY OF J I� rc D<x
Lowe's Home Centers, LLC
By. (Seal)
Print N c 0- j .
Address i9�'//s�1 �� ��•ZLl� (Seal)
ner A A
JD 1-1Cityi MCC loll e (0'�
State/Province Zip/Postal Code Print Name
(Seal)
.Store 1094 Project No. 467836961 for JOHN MANNION Page 4 of 8
STORE COPY
Co-Owner or Witness
Print Name
Customer acknowledges receipt of a true copy which was completely filled in prior to Customer's execution hereof. You the customer may cancel this transaction
at any time prior to midnight on the third business day after the date of this transaction. See the attached Notice of Right to Cancel for an explanation of
this right.
:Store 1094 Project No. 467836961 for JOHN MANNION Page 5 of 8