8A LOVETT ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State® Building Code 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, O�e tc lish a
One- or Two-Family Dw tng
U1` This Section For Wicial Use prify
Building Permit Number: ate Ap ' d:
�
m ding Official(Print Name) Signal Date�
SECTION 1: SITE INF ATION
1.1 Property g�AddresLs: 1.2 Assessors Map&Parcel Numbers
�re-l+
L l a Is this an accepted street?yes no Map Number Parcel Number w
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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 ifyes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'o Record:
P�gI lyiu `rGr566K- .1�g JeoM in R o 14 7D
Name(Print) City,State,ZIP
RA Uu�44 51 . 47r1- 714-OW
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
1
rQl , bY1Q,
SECTION 4:ESTIMATED CONSTRUCTION 90STS
Estimated Costs:
Item Labor and Materials Official Use Only
1. Building $ % ,y 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ / ❑Total Project Cost'(Item 6)x multiplier x�
3. Plumbing $ i 2. Other Fees: $
4. Mechanical (HVAC) $ i List:
. � �] i ��
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ` I, 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 71 177
YSha1A 6tT�(h License Number Expiration Date
Name of CSL Holder
17, J r List CSL Type(see below)
No.and Street Type Description
� U M� DI U Unrestricted(Buildings u to 35,000 cu.ft.
City/Town, P R Restricted 1&2 FamilyDwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Tele h ne Email address D Demolition
5.2 Registered�H��o�me Improvement Contractor(HIC) I )I�6 lb (3 J
LoLits [ tag) l an'r'c/C HIC R listmti n Numba Expiration Date
HIC Company Nam or HIC egistrant Name
136 TUf4h01X
No. dSr [ s
,Ur a ma o 1?76 c 7-3s9-09(X
Ci /Town, State,AIP 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 SkUTHORIZATION 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.
',OtUd al rt [Soo�- & 12
Prit t'bwner's Yarne(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 e d curate to the best of my knowledge and understanding.
�91f C kalOAV IK 10 b 12-
Print Owner's or Authorized Age it 1 me gnature) 471 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
www.mass.*off v/oca Information on the Construction Supervisor License can be found at www.mass. og v/das
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"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
k9 Boston, Mass. 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
NamelBusincss/Urganindion/Individual) : RonoAa \11JC&(bJjj0
Address: 12 -7"Jk PS C-+
City/State/Zip: Test MA 01gbo Phone#: 97$" 6-3a-o3S;L
Are you an employer?Check the appropriate box: Type of project(required):
1. ! 1 am an employer with 4. 1 am a general contractor and 1 6. 1 New construction
` r employees(full and/or part time).* have hired the sub-contractors ?, Remodeling
_.y 1 am a sole proprietor or partner- listed on the attached sheet.
I- ship and have no employees These sub-contractors have 8. i Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance. 9. i Building addition
required] 5.-1 We are a corporation and its 10. 1 Electrical repairs or additions
3. l 1 am a homeowner doing all work officers have exercised their 11 -I Plumbing repairs or additions
myself [No workers' comp. right of exemption peen MGL
insurance required] i c. 152, § 1(4),and we have no 12. 1 Roof repairs
employees. [no workers' 13. -1 Other
comp. insurance required.]
*Any applicant that checks box#1 must also rill out the section below showing their workers'compensation policy information.
tHomeowners who submit this aRidacit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
;Contactors that check this box must anach an additional sheet slowing the name ofthe sub-contractors and state whether or not those entities have employees. If
the sub-contractors have emplovees,then must provide their workers'comp,policy number.
l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job.site
information.
Insurance Company Name:__ Act AYherirnh —Xhsur6ntle 9!6rieckn
Policy #or Self-ins. Lie. #:_ 6 F C all B'4 80 S P 0 1 a Expiration Date:_
Job Site Address: 8A_LQtt Tts 1 .��- City/State/Zip: _--k Qe _ tooff ti/ 4?AD
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 152 can lead to the imposition of criminal penalties of a tine
Lip 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
$250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification.
I do herby certify under the pains and penalties gjperjury that the information provided above is true and correct.
St; nature. /c� �j�Q�p `- Dote' Q7g^$3'� 035�
Print Name: Ron M W0,C)" itx Phone#
Of.ficial use only Do not write in this area to be completed by city or town official
City or Town: Permit/license#:
Issuing Authority (circle one):
I.Board of Heath 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5..Plumbing Inspector
6. Other
Contact person: Phone#:
F.�:.. �� L/OmU/K09uU¢OA.[2 �✓/�I.Cldd¢I%HA.[OGI.W
�\ Office of Consumer Affairs&Business Regulation
�. OME IMPROVEMENT CONTRACTOR
Registration 48688 Type;
Expiratwn 10/18/2013 Supplement ,
k
LOWE'S HOMESaCENTERS INd�
F
RICHARD CHALONE� 1= T-
` 136 TURNPIIt KE RD�$U1'TE 100?
SOUTH BOROUGH;MA'.0'7`�72 Undersecretary
011ice of Consumer Affairs&B siuess Regulation License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
_ Registration: 133414 Type: Office of Consumer Affairs and Business Regulation
Expiration: 6/27/2013 DBA 10 Park Plaza-Suite 5170
RO CO CONSTRUCTION Boston,MA 02116
RONALD WACHLIN v J
12 TUCKERS CT. � �'_
PEABODY, MA 01960 � —c_
Undersecretary Not valid without signature
�lassachnx'tts - Dcp+u'ttmcot of Public �;dcts
Board ttf Building R(_ulatiun. and �t:uul:u'd.
Construction Supervisor License
License: CS 71187
RONALD E WACHLIN
12 TUCKERS CT, 3RD FL #'
PEABODY, MA 01960
Expiration: 8/4/2013
( „nmii..i„urr
Try: 20503
11-01-11 ; 16`. 12 ;patrick-j-woods-insurence 9788800023 ;9785318617 # 2/ '3
GRTIFIGATE OF LIABILITY INSURANCE ioio3jioii
Pao "R 978 s S31.2777 FAX 978.S31.8617 THIS CERTIFICATE 69 L93UED AS A MATTER OF INFORMATION
P:]. ,Woods Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
40 Main St HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
P.O. BOX 353 ALTFR THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Peabody, NA 01960 INSURERS AFFORDING COVERAGE NAIC S
INSURED Ronco Construction, Ronald Wac Tn D a INSURERA CONNERCE INSURANCE CONPANV 34754
12 Tuckers Ct. INSURER D:
.Peabody, NA 01960 INSURERC:
INSURER D;
INSURER E:
COV
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VVIYH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFPORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
RIRR AbtpkTYPE OF INSURANCE POLICY NUMBER POIJCYEFPDCTIVE POUDYEXPIRA710N
.LIR EnuMI TO
GENERAL LIABILITY NV7121 11/03/2011 11/03/2022 EACHOCCURRENCE S 500,00
�( COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED S 50,00
CLAIMS MADE OCCUR MED EXP(RAY ww Peman) S ' 51000
A _._ PERSONALS ADV INJURY Is
GENERAL AGGREGATE $ 1,000,0
GERLAG(RREGATE LIMIT APPLIES PER: PRODUCTS-COMPfOPAGG 6 1,00010
00
X)POLICY Loc
AUTOMOBILE LIABILITY VK0743 02/14/2011 02/14/2012 COMBINED SINGLE LIMIT
`ANYAUTO _ (EL lLGkAAE) $
ALL OWNED AUTOS
X. SCHEDULED AUTOS BODILY INJURY S
A - IFRpereaU 100 0
X HIRED AUTOS
00
BODILY INJURY S X NONOVJNEDAVTOB (PnauAenl) 300
.000
PROPERTY DAMAGE 6
. leereCclderrtl 100,000
OAPAGE LIABILITY AUTOONLY-EAACCIDENT $
ANY AUTO OTHER THAN EAACC S
AUTO ONLY: AGG 6
EXCEMMBRELLA LIABILITY EACH OCCURRENCE 6
OCCUR CLAW MADE AGGREGATE 6
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6
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EMPLOYAW LWMLDT
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OFOFFIC&W dftaftio�ER EXCLUDED?wmw E.L.DISEASE-FJI EMPLOYE
6
'IALPROVISION NIW OTHER EL 018EABE-POLICY LIMB S
OF ODE, ILOCATADNSI VEHIGLm/EXCLLSIONIS In4D��aa RY LNIDORBEMEWISPf:CWI PRov�q Ng
T� Inc & any and all subsi aries are named as add'1 insured as respects to general
iabTllty and .aut0 liability.
OOS FoNd:.F550,5uper Cab, 1FDAX57Y1SES5445 2005 CARNATE TRAILER SAK816MSL0104538
OLIO CAR14ATE TRAILERS, 5A3C6105XL0004012 2002 DODGE DURANGO, 1B4HS78X62F118138
77 TEHOL ANCELLATION
_ SHOULD ANY OF THE ABOVE ONCR IBED POLICIES eE CANCELLED BEFORE THE
EXPIRATION DATE TRERLOF,THE 199LUNG INSURER WILL ENDEAVOR TO MAIL
LOW"$'CIMIPANIES, INC, 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMEDTOTHELIFT,
15 INSURANCE BUT FAILURE TO MAIL SUCH NOTICE SHALL 99POSE NO OBLIGATION OR LIABILM
P"OzB0X;1111 OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVE&
•" WICKEBORD NC A D REPRESENTATIVE
AGO.R0.2 (Whoa) FAX. 336.6S8.2308 ®ACORD CORPORATION 1983
11-01-11; 18: 12 ;patrick-i-woods-insurence 19788800023 ;9785318ti11 4 ii a
PRGDUCYR- - - 'rx6GKwI'IFT wl F.IN ISSUEDASAMA'1' KOF INF(IRMA'11ON ONLY
WOODSP'J INS AGCY INC AND") MANNORIC", t1PAN'tYrECRR17R1(A'pRIIOLUEtt WIN
PO BOX353 AFFOFR'A'R IRIRNNOTA llDK leX'r14ND(11(AI:TY.R'lY1KCYJVyRAGR
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PE"ODY, MA 01960 !r�/�fr p
G� CORANE AFFORDINGCOVERAGE
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. _ 1NIM',ATEO.NOT�VI 'IA]YDINO AFIY RPpUIRIDrffiNI TPRM OR GONDRION OF ANY CONTRACT ORUTHADOCIL)TENT WITHRESPUl TO WI.1R817WS
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STORE COPY
INSTALLATION SERVICES CUSTOMER CONTRACT- WORK- INT/EXT/PATIO DOOR
A # LOWE'S OF DANVERS, MA.,STORE# 1094 STORE PHONE: (978)646-9099
153ANDOVER STREET SALESPERSON: NESSIEM KHOZAM _ t
DANVERS, MA 01923 - SALESPERSON ID: 1007888
Document Print Date : 09/01/2012
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-
tyment, including the„specifically completed pages of this document; the
and Conditions included with this document, the applicable portion(s)tion(s) of Lowe's receipt, and any Y
, ,other addenda or attachments hereto;shall be referred to herein as this "Contract:"-,
i 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; Inc.'s.MA HIC NO.: 148688 Lowe's Home Centers, Inc.'s FEIN: 56-0748358
Customer Name Home Phone
(
$' BEVERLY TARSOOK ,;,, f' 978-744-0686
: .
01 . Customer Address Other Phone
c..
8A LOVETT ST
City + *„ ,State/,Province Zip/Postal Code
TM® SALEm _MA. , 01970 j
Installation Address
8A LOVETT ST w m S
j) Installation Zi /Postal Code Installation City + '� � z*.� � »��;. Installation State/Province �. p
t
`=® s SALEM 1 fir'; Mp?` 3 . 01970
..,f rAMEFiCHAND9SE %ARID INSTALLATION SUMMARY
r
''• '' *_s ' z >;, MERCIiAN®ISE_SUMMARY
. ,Q108938 43156171392 STK BB COMBO KNB GEORG BB COMBO KNB GEORG, - QTY, 1 1
a .x39683 : PRODUCTCODE SOS 'SOS RB COMMODITY FBRGLS DORFAB TC : ENTRY/EXTERIOR SINGLE UNIT,.6 PANEL'. DOOR FABRICATION SER j
r VICES INC 'QTY 1^ , 4 {
; 131207 131207�STK 1X8X16 PRIMED FINGER JOINT 1X8X16 PRIMED FINGER JOINT IRVING:FOREST PRODUCTS (MAINE) CITY 2
t z r materials Price $464.41 Jt
IP
-a t '.• x
fi
$ °S li �tALLA'I'ION ®ESCRIPTION
'' 4 v+S'
Store 1094 Protect No 362313336 for BEVERLY TARSOOK » R_ Page 1 of 7-
Y.42.tt^T
§s+t�''� t •rnyk,r�'�` �Po1SR.�„i rG�i Fn.Y"*.Ky U,u�.� k>a �ti.i'S,..:6 $� � _� .+�` r.. ,rem '` � ��' y ,t
STORE COT
Stock or SOS: SOS.;. ,Door Type'. Exterior
Select Location : Back Door Select New Door : Single Pre-hung t
Number of Doors to Install : 1. Side Lights or Transoms : No 4,
Hardwood (Mahogany or Oak) Door : No Hidden Damage Description : None
Number of additional holes bored for accessories : None Install Specialized Mortise Hardware : No
Install Storm Door - No Lead Safe Practices : No
Total Linear Feet of Custom Trim to be Installed '0 a 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
i -Local Disposal;Fee : Yes ,D.escribe Other Work Needed ; install in masonary, Gust. trim work
Other Work Charge Yes' Comments : No Comment
-
1 Labor Charges
Detail Deduction $ 35.00 I
_ r ,
x ,
Addrtional,Specifications: '
Notation: Lowe's will not,'inake structural modifications ,paint or'stain or remove/reinstall security system equipment. Customer is responsible to advise if prop e
erty is governed by Historic District Regulations ZN,
Additional Specifications:Federal law requires°Lowe's to provide you withAhe,pamphlet Renovate Right: Important Lead Hazard Information for Families,'
.;Child Care Providers and Schools. By signing this Contract;)C,ustomer`ackpowledges having received'a copy of,this pamphlet before work began informing, f
f Customer of the potential nsk'of the lead hazard exposure from renovation`activity,to:be performed in Customer's dwelling unit. i
r,4p,44m
+ '.. TO TA CI"IAFiCaES:.OF ALL�IVIERCHANOISE �IVD $E.RVICE$` � ' •where applicable � .. .
r � SUB-TOTAL -$961. 1 a
g:y TAX $ 0.0
b - r Mek zd v + ♦:: a�.'a. � 'S�+. " .. T E c 1�' ivY m r a r _
N a N" a, 1 a 4 DELIVERY 00
x w a' m fi
ORDER TOTAL $ 961 41`
�' '.Y3 Y+ h aee .3w^ My
'BALANCEAUE
^ .,,�' .9 � a �s� °� ,• ,y's,.,2 dfiR� ,.e x s s t x. '� F a 4
.e'..w
T n F
i u3...Nttc.tit: a., ♦*P'.. .. a .� e :.. .. �.y • en'
Page�2 of 7�
�Store�1994 Protecct No 3623133361or BEVERLYTARSQOK 1 �
STORE COPY
Work is to commence upon reasonable availablity of Contractor which is anticipated to b [fill it date].
Estimated completion date is f r L [fill in date].
I
NOTICE TO CUSTOMER ..
AII`items listed'in this contract and specification sheet(§)'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,ofattachments. Extra labor or material incident to installation
xh.. ... . m. -
necessitated by defective substructures;'superstructure; points of:attachment; or the moving of fixtures or appliances to be billed at extra cost to custom-, g
er:
IF THE CONTRACT TOTAL IS $1 000 00 OR LESS Customer must lay in full.
_ E
COMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS$1.000.00 t
[_] Customer to Pay in Full; OR y
`❑ Customer to use the following payment schedule �.cw' � � �t � �`4
(1) Deposit $ to be paid upon signing contract. Deposif should be 1/3 the total icontract price; and
(2) Payment of $ to be paid-anytime after this Contract is signed and before commencement of installation, I/We authorize Lowe's to do
one of the following (check appropriate box below). ,' '
[_] Charge my/our credit card for the amount of the payment indicated above:anytime-after the date this Contract is signed; or.
[ }Deposit my/our check for the amount of_the payment mdicatediabove anytime after the date this Contract is signed; and
(3) Final payment of$100 00 to be'paid upon completion of the installation;and both parties'satisfaction.
DO NOT.SIGN THIS,CONTRACT IF THERE ARE ANY BLAN_KxSPACES AND,UNTIL YOU HAVE READ THE TERMS AND CONDITIONS CON-
T.AINED IN THIS CONTRACT AND WHICH FOLLOW,,,,-. SIGNATURE- PAGE(s):BYySIGNING BELOW, YOU ARE ACKNOWLF_DGING THAT YOU a
v HAVE READ,:UNDERSTAND AND AGREETO TH,E•TERMS AND CONDITIONS SET FORTH IN THIS CONTRACT..YOU.ARE ENTITLED TO A COPY ,
OFT CONTRACT AT THE TIME OF SIGNATURE- ,
r
NO TICE_REGARDINGARBITRATION AGREEMENTfOR CLAIRA VERED BY.M.G.L. C.142A z (f
LOWS S AND'OWNER; HEREBYMUTUALLY'AGREE IN ADVANCE THAT IN-THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CON- 9
` -TRACT THAT LOWE'S MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS]BEEN APPROVED BY THE SECRET
' ARY,OF THE EXECUTIVE;OFFICE OF CONSUMER;AFFAIRSAND BUSINESS REGULATIONS AND'--THE OWNER SHALL BE REQUIREDyTO SUB-`
MIT,_TO SUCH A BITRATION AS:PROVIDED IN
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Store 1094 Protect No 362313336 for BEVERLY TARSOOK ,
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STORE COPY
BY Dater
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Owner
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By: Date:_
S P-oiase a
:n THE SIGNATURES'OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION
a INITIATED-BY LOWE'S PURSUANT TO'M.G.L. c 142A' THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION
EV N'WHERE THESECTION ABOVE IS NOT SEPERATELY SIGNED BY THE,PARTIES.
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WITNESS OUR HAND(S) AND SEAL(S)'BELOW THIS DAY OF
.Lowe s'Home Centers, Inc. - - - -
' By.—� (Seal) i
Print Name: L
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R Addre s Ow er '
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i .City State/Province Zip/Postal Code > print Name
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�Co-Owneror Witness - ,.
9Print Name
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lCustomer acknowledges receipt of a true copy which was'completely filled m.prior to Customers execution hereof You the customer may,cancel this transaction,
t at any:,time prior_ao midnight on the third business day after the date of th_is transaction See the attached Notice of Right to Cancel for an explanation of
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Store 1094 Protect No 362313336 forYBEVERLY TARSOOK ' ' ; a r c Page 4 of 7 '