4 MARION RD - BUILDING INSPECTION 1
A The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
m OFSALEM
r
Massachusetts State Building Code, 780 CMR, 7 edition
RevirrdJunnory
G Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 20011
One-or Two-Fgmily Dwelling
This Section'For Official Use Only
Building Permit Number: 1 Date Applied:
i
Signature: =k4
Building C mi"ioncKIns t uildings Date �-
--[—SECTION 1:SITE INFORMATION
1.1 Property Address: t 1 1.2 Assessors Map di Parcel Numbers
I.la Is is this an acceptcdstreer?yes . no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lol Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) A�esnr� �
Signature Telephone
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'': '—Zsp�&,� t- P
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S I. Building Permit Fee:S Indicate how fee is determined:
O Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire
Suppression) S Total All Fees:$ y
Check No. Check Amount: Cash Amount:
6.Total Protect Coat: ❑Paid in Full O Outstanding Balance Due:
'�ta� -"cam
t
SECTION 3: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) � � � ��
I.icense Number Expimlion Date
Name ol'CSI.• I(older _ /�•�_�� I.ist CSL type(see below)
f. Uescri lion
:\�J��s—sy/3� U llnresuicteJ u to 75,000 Cu. V.
R Restricted IB2 Famil Uwellin
Signatu M M Onl
RC Residential Roulin Coverin
tme WS Residential Window and SiJin
SF Residentiol Sot(d Fuel Bumin A liance Installation
D Residential Demolition
6. Registe ed Ho Imp vetnent Contrac r IC
AddC�
me ur IIIC Registrant N• Registrrtion Number
�eV S� PEt iration Date
elephune
i
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 2SC(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 Issuanc f 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
1 , 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.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are We and accurate,to the best of my no "ledge and
behalf.
Print Nam
Signatu ed Agent Date
Si r the sins and tes of 'u
NOTES:
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�L have access to the arbitration
program or guaranty fund under M.G.L.c. 1 J2A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 1 IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 halfftihs
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
}. "Total Project Syuare Footage"may be substituted for"Total Project Cost"
y CITY OF SALEM
PUBLIC PROPRERTY
J DEPARTMENT
MJ W;nI I iY:JNISCULL
MA)OR 12C WASHING ION STREET • SALEM,MASSA(a It Sc rl S 0197C
'fLt.;978.745-9595 • Pox: 978-74NJs46
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibly
,inirle tnosiness/OroanizuioNlndividuall:
Address: �1=-P-/,/
Ci[yS[n[c;'%ip: U`� //'�' -r�l'honefl: 50F
:ire Nan employer:'Check the:appropriate box: Type of project(required):
1. I :mt a employer with 4. ❑ 1 :un a general contractor and I 6. ❑ New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ I am a sole proprietor or partner. listed on the attached sheet.. �• ❑ Remodeling
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' cum insurance 5. ❑ We are a corporation and its
I P• 10.❑ Electrical repairs or additions
I required.] officers have exercised their
exemption ri ht of per MGL 11.❑ Plumbing repairs or additions
3.❑ 1 am a homeowner doing all work g P '
myself. [No workers' con p, c. 152, §1(4),and we have no 12.❑ RRpof repairs
insurance required.] t employees. [No workers' 13.IJ other �- "rS'
comp. insurance n:quired.]
-Any:q,pticunt that chucks box al must albo till ottt the N-cuon wow showing their wotkus'cumpensation policy information.
'I lomeownen who submit this affidavit indicating Ihcy arc doing all work aml Ncn him outside emumcton must euhmit a new affidavit indiubng such.
{Comm tors thus check this box must attxhdd an additional sheet showing the nano of the sub-contractors and their w'urken'comp.policy mformarion.
l aon wt employer drat is providing workers'c•ompensalioa insurance for my employees. Below is the policy and job Nile
infornnation.
Insurance Company Name: G
Policy k or Self-ins. Lie.#: Expiration Date:
Job Site Address: �r City/Stateizip:
Attach it 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.`vIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$230.00 a day against the violator. Be advised that a copy of this statement may be t'urw•arded to the Office of
Invcaligatiuns ul'the DIA for iosutarcc coverage vcriticatiun.
l do hereby certify under th pair ' enaltics of perjury that the infuriation provided above ins true rued correct.
S •ruure __.. Date: �.J vD
Ih l
Official use only. Do not write ire this area, to be cuntpleled by city or love oJJic•ial.
City or Town: . .. ...- Permit/Liccnse'd._—'_--
Issuing %uthurily (circle one):
I. Board of Ilealth 2. Building Department 3. Cityffon it Clerk 4. Electrical luepector 5. Plumbing Inspector
6. Other ,
Contact Person: ._.__ Phone B:
Information and Instructions
,\Inssachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an emplgyee is defined as"...every person in the service of another Under any contract of hire,
express or implied,oral or written."
.\n employer is defined as"an individual, partnership,association,corporation or tither legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of;m individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152. §25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, NIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of co ipliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractor(s) name(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
.Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retuned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line. -
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
111case be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennidlicetse applications in any given year,need only submit one affidavit indicating current
policy information (if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by time city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bur leaves etc.)said person is NOT required to complete this affidavit.
fhc Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Deparunent's address, telephone and fax number: _
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05
www.mass.gov/dia
A�D® CERTIFICATE OF LIABILITY INSURANCE DATE6MW2
0'
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER AND THE CERTIRCATE HOLDER
IMPORTANT: N the eertl8eate holder is an ADDITIONAL INSURED,the poliey(les) must be endorsed. N SUBROGATION IS WAIVED,subject to
the terms and conditions ofthe policy,certain policies Trey require an endorsement A statement on this certificate does not confer rights to the
certificate holder in lieu of such ondorsemen
PRODUCER TAD _
NAME:
Choice Insurance Agency, Inc. PHONE
UUM N.Evil Nd:
376 Summer Street ems;
Fitchburg, MA 01420 PRODUCERo�Rins. 12683
INSUIE S AFFORDIMi COIIEMeE NAIC r
INSURED INWRERA:Nautilus Insurance COm an
David Sousa S Jean Melo DBA INSURMS:Liberty Mutual Insurance
Safefire INW RE R C:
47 Princeton Street 9220 INSURERD:
Leominster, MA 01453 INSURER E:
1NSIReRF-
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER
THIS IS TO CERTIFY THAT THE POLICES 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 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 CONOTIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAW.
LSRTTFFtt Am PoucIf EFF oucr � LafTS TYPE OF WSUWWCE PM mmm MIreIY MWDOrYYYV
Gel9RALLUUmdTY EACHOCCURRENCE f 1 000,000
TL COMMERCMLGENERALLIABIUTY WMAGET Eao=D $ 50,000
p CIAIMSAMDE ❑X OCCUR NC855651 6/11/10 6/11/11 WDE%P(ArVorepamn) $ 5 000
PERSOMLSADVINAIRY f 1,000.000
GENERAL AGGREGATE f 2,000,000
GEN-LAGGREGATE LIMTAPPUES PER - PRODUCTS-ODMPOP AGG S 1,000,000
POLICY n
PRO LOC S -
AUTOMOBILE LIASU T' COMBINED SINGLE LIMIT $
(Ea aoddBnl)
ANYAU10 BODILY IMURY(P®Person) f
ALLOWTEDAUTOS BODILY IWURY(Per a eM) S
SCHEDULEDAUTOS
PROPS ici Cf f
HIREDAUTOS Pmaalasm)eni)
NCNOWNEDAUTOS S
S
UMBRELIAWIe OCCUR EACH OCCURRENCE f
EXCESSLUUS CLAIMS-MADE AGGREGATE
DEDUCTIBLE $
RETENTION
B WORKERS COMPENSATION ,j,Q BE ASSIGNED 6/12/10 6/12/11 X: WC STATU- DIM
YIN
LlAellfY
ANYPROPRIETORIPARTNERID(EO11NE YIN NIA EL.EACHACOCENT f SOO ODD
OFFICERAEMSFR EISIIDED9
ffarda"in HH) E.L.DISEASE-EAEMPUN $ 100,000
K yyea,dwWt,e under
DESCRIPDONL CPERATIONSCNow E.L.DISEASE-POULW LU.IR $ - SOO OOO
MSCRIPTKINOFOPERATXINS I L.00A71M I VMCIES Indwell ACORD lel,AdMio al Relnde Scledrb,Hnom spew Nmglllell I
Operations of Insured
CERTIFICATE HOLDER CANCELLA710M
SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED N
Real Deal Home Inc. ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORRED REPRESENTATIVE
Mary Woodard
®1988-009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009109) The AC ORD name and logo are registered marks of ACORD
� S
CITY OF SALEM
. h PUBLIC PROPRERTY
DEPARTMENT
171: v7S-?a;'1;')5 ♦ I .\s: 775.74 9846
Construction Debris Disposal Affidavit
(ICILI rtl lur all demolition and icnovation work)
In accordance with the sixth edition of the State Building Code, 780 CINR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit H _ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal Facility as defined by MGL c
t 11, S 150A.
The debris will be transported by:f name of hauler)
The debris will be disposed of in
_ S(name of facility)__
fnddress of fuciluy)
_naturc of pern tt applicant
�fl
'late .-.—--
Johi i.�il do.
r
SOLD, FURNISH & INSTALLED BY MA SALES: 774-287-9838
CT SALES: 203-314-9878
F.I.D REAL DEAL HOMES, INC.
26-1632065
■ . ■ ■ 77 Beaver Street • Milford, MA 01757 JOB #
MA LIC. NO. 161097 CT LIC. NO. 0619698 N.H. LIC. NO. R.I. LIC. NO.
ROOFING CONTRACT
SOLD �NNA A-NA Y
a�,, T� c� �" DATE
ADDRESS L4— M146%) 12.Y CITY 3` &IIIn STATE ZIP
/�O G�
PHONE HOME( ) WORK( 3 z We P EMAIL .[]rC E=E A k) 4�r'�' (910l r�t—
JOB SITE ADDRESS(IF DIFFERENT) -
APPLIED ROOFING SYSTEM
General Description of Work at Above Address: Type of House: ❑Frame ❑Masonry.
Approx Start Date: Approx Completion Date: (WEATHER&MATERIALS PERMITTING) (REQUIRES
Approved materials will be furnished and installed to these specifications.
PLEASE READ CAREFULLY:ONLY ITEMS CHECKED"YES"ARE INCLUDED IN YOUR ORDER.
YES NO YES NO YES NO
1.- ❑ REMOVE EXISTING layers of roofing down to wood deck 15.❑ APPLY ROOF LOUVERS 24. ❑50 CARPENTRY-REPLACE FASCIA BOARD
or wood slats Spec) ❑Front Elev. ❑Aear Elev. ❑Lefl Elev. ❑16 ❑1x8'
Specify❑Front Rev. ❑Rear Elev. ❑Left Elev. Areas ❑Right Elev. ❑Other 254 ❑ CLEAN UP:Property at completion at work.
Areas. ❑Right Elev. (3Partial AENire 16. ❑ T(SOLID VINYL SIDING - Cover only flatwall areas
❑Dormers 26:=4 ❑ to beINSURANCE i.All workman's compensation and liability
U designated for siding o he maintained
❑other Size Color❑Details Pattern Package 27 6'1 ❑ WARRANTY:Mail to customer alter completion and full
Custom carrier posts color payment is received.
2. ❑ f0 RE-ROOF remove any turfed or disfigured roof shingles 17.❑-V SIDING ON DORMERS&/OR ADJACENT AREAS 28.X Ef PAYMENTS. On NON-FINANCED orders installer is
&discard at discretion of installer Specify❑Front Elev. El Rear Elev. ❑Left Elev authorized to collect progressive payments.
Specify❑Front Elev. ❑Rear bev ❑Leh Elev. Areas ❑Right Elev, ❑Partial ❑Entire 29. ❑ PRE-EXISTING CONDITIONS OR LEAKS NOTED
Areas ❑Right Elev. ❑Partial ❑Entire El Comments) ❑ ADDITIONAL WORK Not Specified Above
❑Dormers) ❑Other ❑ Work Not To Be Done
❑Other ❑Details ❑ Repair or Replace the Following
❑Details
18,❑ Cq GUTTERS/LEADERS Not responsible for damage _
❑Remove Existing during raiwmal dd,y ?QrA �
3. .1� ❑APPLY Nf�ROOFI SHINGLES g n AD
Brand [-'h7F Al,r _ ❑Discard ❑Save for Homeowner r
0 Re-Install Existing
- Style ❑Replace wish new custom seamless 8leatlers:utters
Color L tom— ❑White ❑Brown g
4. It ❑NEW ROOFING SHINGLES will be applied to the following ❑Other ,;.(�
areas only 19.0 .a APPLYVALLEYS OF 010' -
S,wily❑Front Elev. ❑Rear Elev. ❑Led Elev.
Areas. ❑Right Elev. ❑Partial <nlire 20.❑ Glii ATTIC FAN-No Electrical
❑Domer(s) 21.❑ gSKYLIGHT(S)-Apply Flashing
❑Other 22 IT-Cover with approved
❑Details LID Vft04 SOFFIASYSTEM.1/3 Vented.
Color 1WNN,4G
5, ❑ 'JIM-APPLY GS Fill Cold Applied Modified 23. 0 UeFASCIA-Custom wrap with approved
Bitumen Rubber Roofing VINYL CUD ALUMINUM.
MW'wyd 46011/4 Color-
6. ❑ XBOOFDECKING-
j Areas ❑Right Elev. ❑Partial ❑Enlire ...... w.��cu wwc
❑Dormer(s) ❑Other ❑ Work Not To Be Done
❑Other ❑Details ❑ Repair or Replace the Fallowing
❑Details
1S. ❑ aq GUTTERS/LEADERS Act responsible for damage
3. 'f ❑ APPLY NfJh ROOF SHINGLES ❑Remove Existing during removal — i�
Brand �- �� k�� ❑Discard ❑Save for Homeowner r
Style •1d _ ❑Re-Install Existing r �� 1 l.. _ L
❑Replace with new custom seamless gutters&leaders:
Color = ❑White ❑Brown �..-
4. Jr ❑NEW ROOFING SHINGLES will be applied to the following ❑Omer d
areas only 19.❑ .a APPLY VALLEYS ❑9' ❑10'
Spady❑Front Elev. ❑Rear Elev. ❑Left Elev. p0.❑ ATTIC FAN-No Electrical
Areas ❑Right Etev. ❑Parlial $entire
❑Dormer(s) 21. ❑ GA SKYLIGHTS)-Apply Flashing
❑Other 221 IT-Cover with approved
❑Details LIDVIUJ9FFI SYSTEM.1/3Venled.
Color L
5. ❑ 'A-APPLY GS Flintlastic Cold Applied Modified 23. ❑ UeFASCIA-Custom wrap with approved
Bitumen Rubber Roofing VINYL CLAD ALUMINUM.
ff
Mr4t4o Nowumimr A4 Color
6. ❑ X:ROOF DECKING-
Furnish&Install 5/8'COX Plywood SYSTEM PLUS WARRANTY �y
7. G!"❑SHEATHING - Repla an damaged sheathing at an #' 30-Year Manufacturing Warranty 4 �•; -•
additional cost Of$ per square 12-Year Full Labor Warranty -
INDICATE FORM OF
8. 00 ❑APPLY ICE&WATER BARRIER at eaves,valleys,around Mfg' PAYMENT Z
skylights and pitch changes Style Color Deposit With Order _132%.. $„ 400+'
(ecmrkd»;mmosine'li Ps+ape) Total Investment$ Payment on _aa%- $ _
9. JK ❑APPLY NEW ALUMINUM DRIP EDGE Measure or Start
at eaves 8 perimeter of roof areas IRS 110 1971 R R Balance Due on
10.A ❑APPLY UNDERLAYMENT ❑Shinglemate® }� —Year Manufacturing Warranty Substantial Completion _349'r-$�
4010 Felt Paper C)151b Felt Paper #2 _Year Full Labor Warranty Total Amount of
11. -K ❑APPLY NEW VENT PIPE BOOTS MIq.
Balance to be Financed $
12, 8. ❑NEW COUNTERFLASHING AROUND CHIMNEY(S) Style Color If financed, balance payable in monthly installments
o Lead ❑Copper ❑Aluminum Total Investment$ of approximately$ per month,payable by'Owner"to
O Fiber Roof Cement contractor,but if financed by Owner then Owner will pay said amount
. ❑APPLY RIDGEVENT TO RIDGES to the lending plus such interest and credit service charge of said
13
" lending institution payable directly to the lending institution loaning
❑Cobra® ❑Other y)FT Year Manufacturing Warranty such monies to 'Owner' and will En, ,
Soichy❑From Elev. ❑Rear Elev. El Left Elev. #3 _Year Full Labor Warranty execute a Retail installment ohligation a
Areas.' URight Elev. ❑Omer
A.� Mfg and any documents required by such n
14, ❑ vUAVE VENTILATION- Style Color sending institution inconnectionwilh .r
Supply and Install 3"Round Ventsmid
FINISH OMIB ❑Black Total Investment$
Dc s
*Or
tB11AT1,.. $ -�. �� F� . . .. crA v ANY. �'#Etv1B '', IC�•:.
NOTICE:It financed any holder of this Consumer Crack Contract is subject to all claims and defenses which the SALESMAN HAS NO AUTHORITY TO CHANGE ANY ITEMS OR MAKE ANY REPRESENTATIONS OTHER THAN
debtor could asses against the seller of goods or services obtained pursuant hereto or with the proceeds hereof. CONTAINED IN THIS CONTRACT AND-OWNER"REPRESENTS THAT NONE HAVE BEEN MADETO OR RELIED UPON
Recovery by the debtor shall not exceed amounts paid by debtor hereunder. BY"OWNER".YOU ARE ENTITLED TO A COMPLETELY FILLED IN DUPLICATE ORIGINAL OF THIS CONTRACT.
OWNER REPRESENTS TO HAVE READ AND RECEIVED A DUPLICATE ORIGINAL OF THIS CONTRACT AND TO BE `YOU, THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD
THE AUTHORIZED AGENT OF ALL`OWNERS'OF THIS PROPERTY UPON WHICH THE WORK On THE MATERIALS BUSINESS DAY AFTER THE DATE OF THIS ANSACTION,SEE ATTACHED NOTICE OF CANCELLATION FORM FOR
ARE ID BE SUPPLIED. AN EXPLANATION OF THIS RIGHT.ON A ORDERS CANCELED AFTER THE RECESSION PERIOD,CUSTOMERS
NOTICE TO THE HOME OWNER(S),GUARANTORS),LESSEE(S),CO-SIGNERIS):DO NOT SIGN THIS CONTRACT WILL BE RESPONSIBLE FOR A 45%AD NI STRATIVE AND RESTOCKING FEE'
BEFORE YOU READ IT,OR IF IT CONTAINS ANY BLANK SPACES OR IF IT DOES NOT CONTAIN EVERYTHING AGREED SEE REVERSE SIDE FOR ADD ON TERMS AND CONDITIONS.BY SIGNATURE BELOW,OWNER AGREES TO
UPON,ANY PERSON WHO SHALL HAVE COSIGNED•GUARANTEED 01 SIGNED ANY CREDIT APPLICATION OR THE TERMS OUTLINED ON T R IRIS OF THIS CONTRACT
. NOTE RE ING T)6T S CONTf�gTL1iEREBYACCEPTS TO BE BOUND BY THIS CONTRACT
DATE /V�,��!�""���(� Contractor Acce red
Print Ag/rl ��j-Y/, { rmel
i Salesman's Name V v Signature
Salesman's (um.mer sign Me )
License No Signature
6 (cosron,er Sign Here)