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Home My WebLink About0279 MAPLE STREET e 5 y UPC 12543 a ,' No-53LOR r� 010/3 O �� S oFt r Twn of Barnstable *Permit# G Expires 6 months from issue date ftAfITZgulatory Services Fee 3 S snxxsra§� � d y v� , ; `0� 9 1013 Thomas F.Geiler,Director OF Building Division (V 0,A1, BA �4Tom Perry,CBO, Building Commissioner �N8r �LE 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Map/parcel Number 3 2 o V 1 Not Valid without Red X-Press Imprint Property Address � 7 / M PEE 5f, UJ 5T BQ�uS7/tb1Q Residential Value of Work$ 0 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address �t7NGST �0 dRN C f�s�iiG�1`� .479 M,4p14 St• U - d4"Vr4,01*-, A,¢ 441640'4' Contractor's Name J oh N T Pwum s,ei' d- C•R f i ZZ/ t/orC•4elephone Number J 04 '1471 milli 41ea All ,_?wL Home Improvement Contractor License#(if applicable) /od Iya Email: Construction Supervisor's License#(if applicable) G S d G 7 ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner / © I have Worker's Compensation Insurance Insurance Company Name �f SJa c/�1e�— ` iV to y et-•S �.1, to Workman's Comp. Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑ Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side [� Replacement Windows/doors/sliders.U-Value R d (maximum .35)#of windows 7 old !a4till eX,/��rj O-VPA114, #of doors: e t�t. ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. copy of the Ho Improvement Contractors License&Construction Supervisors License is equ' ed. - SIGNATURE: . C:\Users\decollik\AppDataV Microsoft\Windows\TC(nporary Internet Files\Content.Outlook\8R76BDVA\EXPRESS.doc Revised 061313 Page 7 of 7 Capizzi Home Improvement Inc. Specifications and Estimates STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT WE, ERNEST&JANE CHARETTE, OWN THE PROPERTY LOCATED AT 279 MAPLE STREET IN WEST BARNSTABE, MASSACHUSETTS. I HAVE AUTHORIZED CAPIZZI HOME IMPROVEMENT TO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. I GIVE MY PERMISSION TO LESSEE TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER- ;1 10. A(177 Q OWNER'S ADDRESS: - 2 9 MAPLE STREET, WEST BARNSTABLE,MA 02668 OWNER'S TELEPHONE: _. 508-362-0082 LESSEE'S SIGNATURE: LESSEE'S ADDRESS: ` LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS: 1645 Newtown Rd., Cotuit, MA 02635 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: I Congress Street,,Suite 100 Boston,MA 02114-2017 • www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectliciansJ?Ium.bers Applicant Information PIease Print I,e 'bIv Name(Business/Or nizadon/IndMduai):Capizzi Home Improvement Address:1645 New[own Road City/State/Zip:Cotuit, MA-02648 Phone#:508-428-9518 . Are you an employer?Check the appropriate box: ,/ 40f 4. I am a e IF e of project(required): 1:❑.I am a employer with ❑ general contractor and I employees(full and/or part-tune).* have hired the sub-contractors New construction 2.❑ I am a sole proprietor or partner: listed on the attached sheet Remodeling ship and have no employees These sub-contractors have 8• [J Demolition working for me in any capacity. employees and have workers' No workers' comp.insurance comp:insurance. 9 El Building addition required..] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions J.❑ I am a homeowner doingall'Work officers have exercised their 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 obf repairs: insurance required]t c. 152;=§.1(4); and eve have no employees. [No workers', Ii ' Other comp. insurance required] *Any apr2caat that checks box#]must also fill out the s'wtin below shor?mg their workers'compensation policy infonnation.�" f Hdiueowneis who submit this affidavit indicating they are ding all work.ZW then hire outside contractors must submit anew affidavit indicatng such• $Gonda ors that check this box must attached an additional Shoex showing>th name of the sub-oontractois and$#ate whether or not those entities have employ'ces. If the sub-eantractors have employees,they mustprovide their workers'comp,policy num3e% I:am an employer that isprovidiiig workers'compensation insurance for my employees. Below is the'policy and job site information. Insurance Company Name:Associated Employers Insurance Company .Policy.#or Self--ins.Lic.#:WCC5010 541012011 F.xpirationDate: 12/25/201 Job Site Address: a y f. A(.4.Ple f City/State/Zip: w �� /��/1f�Mo 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 fine up to$1;500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine of up-to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u e pains and penalties ofperjury that the information provided above.is true and correct .Si ature: Date: G.l ,4-Ol3 Phone#: 508-428- 518 :Offcial use only. Do not write in this area,to be completed by city or town officiat City or Town: Permit/License# ['6. sunng Authority(circle one): Board of Health 2.Building Department 3.City/Town Clerk 4.ElectricaI Inspector 5.Plumbing Inspector Oth'erontact Person: Phone#: CAPIHOM-01 CBENISCH CERTIFICATE OF LIABILITY INSURANCE DATE 6(MMIDD 3 Y) 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 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 certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Chris Benisch NAME: _ Rogers B ray Ins.-Dennis Branch 134 PHONE•�):(508)398-7980 FAX No:(877)816-2156 4S3o4uth Dennis,MA 02660 ADDS:cbenisch@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC S INSURER A:Main Street America Assurance Co. INSURED INSURER B:Associated Employers Insurance Co. Capiai Home Improvement,Inc. INSURERC: Capiai Enterprises,Inc. 1645 Newtown Road INSURER D" Cotu it,MA 02635 INSURER E: 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 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 CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVO POLICY NUMBER (MM/DDIYYYYI (MM/DDlYYY1f1 GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY MPB1075H 6/8/2013 6/8/2014 DAMAGE�D RENN 0 PREMISES Ea occurrence $ 500,000 CLAIMS-MADE n OCCUR MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEWL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY JE 4 LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea acciderd) $ A ANY AUTO M1M280" 6/8/2013 6/8/2014 BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ 500,000 AUTOS Ix AUTOSNON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS AUTOS (PER ACCIDENT) X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESSLIAB HCLAJMS-MADE CUB1076H 6/8/2013 6/8/2014 AGGREGATE $ DED I X I RETENTION$ 10,000 $ 5,000,000 WORKERS COMPENSATION WC STATLL OTFI- AND EMPLOYERS'LIABILITY TORY LIMITS I X ER B ANY PROPRIETOR!PARTNER/EXECIITIVEY/N N/A CC5010547012012 12/25/2012 12/25/2013 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEd$ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street Hyannis,MA 02601-0000 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD -.VePa rien4 Of Pubfic Sa e ` Sours o 80-101As Rcqc�1ai3arls and 5ta��;j�r�is i..ict9ose, CS-064817 < :a JOH\'9 S I R.Ul1ShI 1RALDEN 1VY t3uizarrlc Ba+ 1Lk 02 A6 Sti +�=�r�,issittr 06/18/2014 -�� Mace of t oasumer nnesra&uusiness ntguiaesuc Ltcemc air regizu-duuu Yauu iur.iuutrauut uno uuty OME 1MPR 11�1V11 t?CON ff3ACTOF� bebre.the expiratiari date. If fawd returu.ta ` r` Office-of Consumer�ffaits anii B N Regist;at3an�` p� 40: ..._. . ._. fie. 517 Reba mess iatio 10 Park Pima 4� t1 Supploent Card $ostaa,MA 02116 CAO=Ht7 C . , JOHN STRUMSKc--�"�"� 1645 NeM6h Rd. `'_` ,` " a CotttrE,MA 02535 - Uuderseerd2ry Nat v d oat si 3nre A Se ttJ ' /3,1hvf%9dl l I yoF'WE Teti Town of Barnstable *Permit# O Expires 6 montlu fro ss mate Regulatory Services Fee i � � * niSTAB � •� rr"9 16.5 � Thomas F.Geiler,Director Building Division 7' 232009 Tom Perry,CBO, Building Commissioner ` ®VVIV 0', 200 Main Street,Hyannis,MA 02601 QCe www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERNQT APPLICATION RESIDENTIAL ONLY Not Valid without Red X Press Imprint Map/parcel Number rn P I Property Address �� l l�p I� , UV. �/m/A, (U [Residential Value of Work „O '7 J:QG Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Ff lI los_� Contractor's Name, A/Y]8.5 A00/7) Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) Mqo ❑Workman's Compensation Insurance Check one: ❑ I a sole proprietor ❑ am the Homeowner I have Worker's Compensation Insurance Insurance Company Name I Workman's Comp.Policy#_ Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(stripping old shingles).All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑7Replacement side #of doors Windows/doors/sliders.U-Value (maximum.44)#of window ��►KG *.Where required: Issuance of this,permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. io✓+/ ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: Q:\WHILESTORMS\building permit forms\EXPRESS.doc Revised 090809 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Legibly Name(Business/Organization/Individual): OQ� 14 5 so G ING Address: 113 2 4 City/State/Zip:i aOtl150C K d ~ 0),2 s Phone#: ` o l—6/ l— CMo Are yo an employer?Chec the appropriate box: Type of project(required): I. I am a employer with /v') 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑Kem onstruction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. eling ship and have no employees ' These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' comp. insurance.$ 9. ❑Building addition [No workers'comp. insurance p• required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 1 I.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such, tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insuranpe jor employees. Below is the policy and job site information. n Insurance Company Name: e6 C a1 V/ Av Policy#or Self-ins.Lic. Expiration Date: Job Site Address: 2Y P �,f City/State/Zip:W. We 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 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify underthepains andpenalties ofperjury that the information provided above is true and correct. Signature: ic�1,'3� t- �-�.._. Date: �-3 0� Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuink Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: s ec r u^r r We €i gASA_ it'€''A..Mu s.$ex wad reft—M, uss z ss �guta n Won em f L... T # :-286438 _ MOONAV WON a t A,Na �>� Ono mri V, per IA_ ; 3Rr W-im� w , `AT. P NI -DA T Es At" 3Q gdy 43 PA1 M, ROAD �t to Idthe s • From:Shaunna Robinson, Hunter Insurance At:Hunter Insurance,Inc. FaXID: To:Denise Glode Date:923/09 09:45 AM Page:2 of ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID S DATE(MWDD/YYYY) MOONA-1 09/23/09 PRooucrR THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Hunter Insurance, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 389 Old River Road, P.O. Box 1 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Manville RI 02838-0001 Phone: 401-769-9500 Fax:401-769-9502 INSURERS AFFORDING COVERAGE NAIC# INSURED on Associates Inc.DBA Gutter Helmet INSURER A: National Grange Insurance co 14788 DBA Renewal by Andersen of RI INSURER B: Beacon Mutual insurance co. DBA Gutter Helmet Roofing DBA Moon Works INSURER C: 1137 Park East Drive Woonsocket RI 02895 INSURERD: INSURER E: COVERAGES 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 WITH RESPECTTO 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YY) DATE(MM/DD/YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 10 0 0 0 0 0 A X COMMERCIAL GENERAL LIABILITY MVS26619 09/16/09 09/16/10 PREMISES(Eaoccurence) $500000 CLAIMS MADE a OCCUR MED EXP(Any one person) $ 10 0 0 0 PERSONAL&ADV INJURY $ 1000000 GENERAL AGGREGATE $2 0 0 0 0 0 0 GEN L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2 0 0 0 0 0 0 POLICYF_j PERCT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT A X ANY AUTO B1S26619,'., 09/16/09 09/16/10 (Ea accident) $ 1000000 ALL OWNED AUTOS SCHEDULED AUTOS - BODILY INJURY. $ (Per person) HIRED AUTOS NON-OWNED AUTOS BODILY INJURY $(Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ 1000006 A X OCCUR CLAIMS MADE CUS 2 6 619 0 9/16/0 9 0 9/16/10 AGGREGATE $ DEDUCTIBLE $ X RETENTION $10 0 0 0 $ WORKERS COMPENSATION AND S EMPLOYERS'LIABILITY X TORY LIMITS ER B ANY PROPRIETOR/PARTNER/EXECUTIVE 28586 10/01/09 10/01/10 EL EACH ACCIDENT $500000 OFFICER/MEMBER EXCLUDED? If yes,describe under E.L.DISEASE-EA EMPLOYEE $500000 SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $5 0 0 0 0 0 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION BUILDIN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Building Cont. Reg. Board NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Dept. of Administration One Capitol Hill IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Providence RI 02908 REPRESENTATIVES. A DREPRESENTATIVE�^ ACORD 25(2001108) ©ACORD CORPORATION 1988 Co Crr�^7 cG s �C om r Name: ►N!S-t n 4�116N, Year Built: Renewal by Andersen of Rhode Island& � . >�►0 1 C a Cape Cod Ads: �hq��tr a S� Customer ID#: 1137 ParkCod East Drive .� Sales A reemen> (Jesrr6Aigvj;Td3Ld /�_ Order Number:` Woonsocket,RI02895 g City,State,Zip: •� d466 Phone-Home: i Company }I� 5'�fj /�$� !f,?02, Page: of_Date: license#RI-30839 RI-12259 MA- -'hone-Work: — 119535 CT-562725 �LNNf 9=rtr�i^ � RENEWAL BY ANDERSON � � ^' OF CAPE COD Technical Measure GRILLES 1137 PARK EAST DRIVE Dimensions r e ii€ WOONSOCHET, RI 02895 10e - - R - 11 1 e = a'tO '6^ u 48 �n Ng cF c 5 ? Ez tuE c W . car tit 299 0 o 401-671-6400 9 a = _ dg H `s `s e d na€s a =g _ - t: Q '^ ar RICE N na $ $ — _ g r Y P nr m tr L` 'a W'� u7 a c r e 11/24/2009 17:07:48 � d "" � �F r� � sk Vs' Ucl o? r 3 � 5 =�€ � _� �o N � � �� X b N� q� N2 Ella ��. ut a >< G S"I ,i jT 63 Transaction # 3 4 `« a« ' �� 2 � � _ �'0(� ttJ 3 Card Type: VISA 7 1 L ,� :5 3 3 ? 3 Acc: 9305721849855098 �N � .� 3 Exp. Date: 0410 i GL g Entry: Manual ' �N 3 Batch No: 328001 / L ,t) Total: 2000 .00 Reference No.: 00000004 Aut Code: 06923A Resin. APPROVED AUS 1I Resp.: Exact match on address and 2IP code. 4 8 AUS Code: Y CUU2 Resp. Sub Total(npi) Miscellaneous Credits or Expenses P yment Method uj Match nd doo s be provided for the total amount stated in the a ent The (Stain ng Wrap,Ro[Reps r Promotion,etc) O y CUU2 Code: M is subi w ac Fiance by both Customer and Renewal by Andersen Manager as Sub Total(Ades.rages) Description/Notes $Price$ Check 1rG P Sub Total(Nlrages) � �Nr/'Q IC I AGREE TO PAY ABOVE derscn sales Represent signature /f .w/ resit Card TOTAL AMOUNT.ACCORDING /` /TYC 7 Misc.Credits or Expenses y u authorized to f msh a0 windows and doors rcquircd to complete this Financinle TO CARD ISSUER AGREEMENT es to pay the amount stated in dtis agr«men,and accord ng to he terms hereof Total s and Conditions of Sale.You the buyer,may cancel Sgy3, (MERCHANT AGREEMENT IF a rior to midnight of the third business day after Sales Tax ofs Additional order Fortes Attached CREDIT VOUCHER) �-Please�see3c notice of cancellation for an Total Miscellancous Credits or Expenses Work Permit Cost 6 L (please circle all that apply) (arry over total to mist credit I expense column at right) Total Amount of Agreement g YI-0 Paso poor storm poor signatu Special Order Not BaylOow Entry Door Deposit Required / e.(D spedaky Window x SIGNATURE de see Manager s gnamre ' dersen lierravalandrelmtalledon Please note thatwea.unable to bid anrepaldng Balance Due on Completion mtee the of vdrdow owed are arty urtseen damage.Howeveclf any umeen damage Nndow solely theresponsi ilityof isd'ncwend doting installation we will mmpiete Price includes labor,materials,installation, r new oohs the astoner unless and[harge you for the repairs upon your approval. removal,and disposal of products replaced. MERCHANT COPY otherAte noted. At the end of the It a0 amwNon debdswig be removed and we will dean your new windows and White-Renewal by Andersen Yellow-Installation Pink-Homeowner Customer the Installation area. Initials: -rt�o�•w MAar�endd.rt�ar�,lh.s,wr��o.Ra,dra,,,k.<rAad<�c>ma•d^^.emw amra�co�o�mdnu nd,o�.troarua�.tt�wos,.