Loading...
HomeMy WebLinkAboutBuilding Permit #328-11 - 10 LYMAN ROAD 10/19/2010 SAO R Til BUILDING PERMIT °�s�`E° ,6'��0 TOWN OF NORTH ANDOVER o - APPLICATION FOR PLAN EXAMINATION ~y _ Y _h f0 `O °R Permit NO: Z r Date Received �R° .TEoIV"`c5 ,7S CHUB Date Issued: 00, J � IMPORTANT:Applicant must complete all items on this page LOCATION Q. p Print PROPERTY OWNER. Al Print MAP.210-42PARC�L- . . ZONING DISTRICT Historic Dist"nct yes. o Machine $hop Village yes no TYPE OF IMPROVEMENT PROPOSED USE E Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other d Septic p Well p Floodplain D UVetlarids 1Natersh`ed District. ❑Water/Sewer j DESCRIPTION OF WORK TO BE PERFORMED: /"�_`�^��(.e�Gt /e2tY1 tl fes!��i✓3 /7-e -'f C51 Ltt/ffG . Identification Ylease Type or Print Clearly) 69-7 G 6�6 OWNER: Name: �� Cn � d Phone: '?-7g Address: w►An CONTRACTOR Name: Aj-r. r-kPhone. X03 Lhf, 3 )f2 Ad&ess *Z 'a c',Gv d -til Supervisor's-Construction License: Exp:' Date. . Home.lmproverrient License: �`� Exp. Date: �Z ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT;$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ FEE: $ Z X 7, �' 2 : Check No.: pReceipt No.: NOTE: Persons contracting with unregistered contractors do not have access toVarantVyfluSignature of Agent/Owner Signature of contracto `' i Building Department The following is a list of the required i I� forms to q be felled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products DOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers -Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products N OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products 'OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Yn all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals f that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording Must be submitted with the building application Doc:Building Permit Revised 2008 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ [Well YPE OF SEWERAGE DISPOSAL ublic Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ ❑ To Sales ❑ Food Packaging/Sales El Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF(r.U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Siqnature &OMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: — - - Located 384 Os ood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS. Dimension Number of Stories:__Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of No Electrical Inspector Yes DANGER ZONE LITERATURE: Yes No MGL Chapter 166 section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use i I I' ® Notified for pickup - Date Doc.Building Permit Revised 2010/October i-r r Location 14710,4 No. Date , NpRTp TOWN OF NORTH ANDOVER p � t N A i y Certificate of Occupancy $ sJawustt Building/Frame Permit Fee $ ` Foundation Permit Fee $ Other Permit Fee $ a%a T7 - TOTAL Check # 23576 Building Inspector NORTIy O _ .. Andover . . O .:1_ � � 1••1`x'.04,.,�. �' w..4w.. .'�F.. No. = _ (c7 . ( �. o - A K E -o over, Mass.,, COCHICKEWIC �. K y ADRATED S$ BOARD OF HEALTH I Food/Kitchen Septic System .PERM IT T D BUILDING INSPECTOR THIS CERTIFIES THAT.......... .... .. ...........�..�'..�...�`..`... ......................................................................... Foundation has permission to erect.. ......... buildings on .....�..a.......... ..... . ....... Rough ..... to be occupied as.... Chimney provided that the person ccep inthis permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR V OLATION of the Zoning or Building Regulations Voids this Permit. Rough ` ' •�x Z Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU ARTS Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the- Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT' Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE ACCO CERTIFICATE OF LIABILITY INSURANCE °��'MN1D°Y""' �� 6/21/10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Hasbany Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 236 Pleasant Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Methuen, MA 01844 INSURERS AFFORDING COVERAGE NAIC# INSURED INsuRERA Western World MY HOME CONTRACTING, LLC INSURER B: Chartis Insurance Company C/O Don Lucciano INSURER 14 Coffeetown Road INSURER D Deerfi ld, NH 03037 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 RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TOALL THETERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. rA ADD' POLICY NUMBER POLICY EFFECTIVE PTYPE OF INSURANCEOLICY EXPIRATIONDATE(MWDDjyyr0 MMI ffyj UMTS GENERALLIABILITY EACH OCCURRENCE $ 1,000,000 DAMA X COMMERCIAL GENERAL LIABWTY NPP10$0275 1/1610 1/16/11 PREMISESGETO EaoocuneRENTEDnce $ 100,000 CLAIMS MADE F-1 OCCUR MED EXP(Arty one person) $ 5,000 PERSONAL&ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMITAPPLIES PER PRODUCTS-00MP/OP AGG $ 2,000,000 POLICY JECT PRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL O WNE D AUTOS BODILY INJURY $ SCHEDULED A UTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNEDAUTOS (Peraccident) $ PROPERTY DAMAGE $ (Peraccident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANYAUTO OTHERTHAN EA AOC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION X WCSTATU- OTH- AND EMPLOYERS'LIABILITY Y/N FIR B ANY PROPRIETOR/PARTNER/EXECUTIVE 000363832 6/14/10 6/14/11 E.L.EACHAcaCENT $ 100,000 OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under SPECIAL PROMS ONS below E.L.DISEASE-POLICY LIMIT $ '5500 000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Windows and Siding CERTIFICATE HOLDER CANCELLATION SHOULD ANY OFT HE ABOVE DESCRIBED POLICIES BECANCELLED BEFORE THEEXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS wiarrEN My Home Contracting, LLC NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 14 Coffeetown Road IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Deerfield, NH 03037 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Eric Jansen ACORD 25(2009/01) ©1988 2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts ' Department of Industrial Accidents n Office of Investigations 600 Washington Street u Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): m t, RAY" Address: I fee- 'b Gtr., City/State/Zip: �C Q � .( JA U1v? Phone #: 663 X63 ASF f Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 7. Remodeling 20 I am a sole proprietor or partner- luted on the attached sheet. # ❑ g ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in an capacity. workers' comp.insurance. Y P h'• 9. E] Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 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' 13.E] Other comp. insurance required.] *Any applicant that checks box#1 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. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors acid their workers'comp.policy information. I am an employer that is providing workers compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: b. �T Policy#or Self-ins. Lic.#: O obi 63 F�L Expiration Date: Job Site Address:r� L U P"11,n City/State/Zip: AM G?) 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 fonn 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 under the pains and penalties of perjury that the information provided above is true and correct.* Si nature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town offrciaL City or Town: Permit/License# Issuing 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other 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 an 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,MGL 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 compliance 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 p necessary,supply sub-contractors)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 cavy 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 returned to the city or town that the application for the pen-nit 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 surd 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. Please be sure to fill in the pen-nit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current c 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 the city or town may be provided to the %applicant as proof that a valid affidavit is on file for future pen-nits 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 burn leaves etc.)said person is NOT required to complete this affidavit. The 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 Department'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 Revised 5-26-65 Fax#617-727-7749 www..mass.gov/dia achuscrt p.�`— g8ard Of Buildin.. 1 meat of ut l C", Construction Su ~ R�'ulatirrn�:` Satet : rnd Stancl.ar License: CS SL pervisor Specialtyd� 1-100416 LlcehSe. Restricted to: WS JASON FM-.. oa HABE 0 "ORSTROq225 RAYMOND H '" X10 CDDEERFIELD NH �� ?+ 'ck 7d • �' - w o � o c � z O p w f'r nnrri.,. u�net �XAiration: 2/13/2012 I Tr#: 100416 C rr rrr c z � oEj w00 13 Bo dhf i_ `�{ E114 ont nn w `° p a to C HOME IMPROVEMENT CONTRACTOR 1O . Registration: " o 145039 Ln Expiration: :1.2/2/2010 Tr/f. 283100 Type. Individual JASON HABERSTROH. � JASON HABERSTROH Y 200 NORTH RD DEERMELD, NH 03037 Administrator . qj/a0w s vq I 4e- 7 a)(, e4- ecorf. myHOip m Contracting, LL Jolt Date 1 Name A w -t41f V � 0 Address � .L Phone (H) 971 7 0,0 47 a (A) g-j 6o �i l Thank you for to ing the time to meet with me and discuss windows foryour home_ I would briefly 46 to tell you about My Home Contracting,and why you should choose us for your remodeling project. My Home Contracting protects your Proper by covcnnvoyou with$2,000,040.40 of liability insurance.Workmen's Compensation Insurance covers all of our employccs so you are not cxpoSed to any liability. We are Proud members of the Better Business Bureau (BBB).We maintain this affiliation to provide you with the highest level of conRdencc and customer service.All of our employees attend pre-approved on-going training to keep them up to date on the latest tcchnological advances in replacement windows. Should YOUelect to make your home improvement investment with My Home,we shall strive for 100.%customer-,atisfaction. Ver truly yours, Donald F.Lucciano Owner 0,,s.Cn1vr' 40'....� ".. MY HOME CONTRACTING, LLC a Registered In Massachusetts&New Hampshire]MIR 1 , .� a f 5 P.O.Box 984 �` Methuen,MA '� 01$44 * Tel. (978)682-9052 � a"v' • MEMBER P.O. Box 144 Deerfield,NH * 03037 « Tel. (603)463-8898 Toll Free Telephone: (800)921-9052 * Fax(603)463-8911 w%w.myhomecontracting.com • 1 rn ire �.-.�. ....�........... �. ... ------- --- --- - - - Job # This project has been specified in accordance with local building codes, industry standards and manufacturers`specification requirements. All work will be installed by certified craftsman to assure qualifications for the long-terra window warranty. GENERAL SCOPE OF WORK ➢ Remove existing storm windows. ➢ Remove interior stops from the sides and top of windows.(Care is taken to cut the paint line to minimize chipping of the interior finish.) >r Expect paint to chip at joints.Touch up paint of the interior trim is not included. ➢ Remove the existing sashes. A Remove the parting bead if existing at the sides and top. Remove the existing balance systems and fill with fiberglass insulation as required Apply caulk sealant to the interior of the exterior stops. Install the new double hung replacement windows plumb and square.. Screw the new window to the original wood frame. la Adjust the expander on both sides to remove any bow in the master frame. Caulk both sides of the new windows. This will prevent air movement at the perimeter of the windows and reduce any drafts. INTERIOR FINISH Are we installing new interior trim?_A/0 ➢ Caulk the perimeter of the interior with paintable caulk sealant. Clean all windows upon completion and vacuum work area when done. ➢ Canvases are used during installation when needed. ➢ Any painting or staining isMt included in this proposal. TAILS Are we wrapping window casings? EXTERIOR TRIM DETAILS PP ➢ Fabricate PVC coated aluminu , tri tock to cover the window casings,joining the corners with 4.5- degree angles. Color � Qty ➢ Use 9900 SOLAR SEAL for caulk around all window trim. This advanced caulking is based on terpolymer technology, which offers an altemative to silicone and urethane sealants. Its high performance terpolymers impart exceptional weather-resistance, adhesion,elongation and color fade resistance.Color to be matched to exterior trim color. •' MY'TOME CONTRACTING, LLC ' Registered In Massachusetts&New Hampshire r r P.O. Box 989 * Methuen, MA * 01944" Tel.(978)682-9052 NtEMlft P.O.Box 144 * Deerfield,NH * 03037 * Tel.(603)463-8898 Toll Free(800)921-9052 Fax(603)463-8911 www.myhofnecontrar,ting.com 2 Job # _ t DOW SPECIFICATIONS Total Windows Qty Qry Purchased Bow Window Double Hung Z-� 4 Lite / 5 Lite Picture Window Garden Window Patio Door 2 Lite Slider 5 ft. / 6 ft. / 8 ft. / 9 ft. / 12 ft. 3 Lite Slider Entry Door Traditional / Equal Single Casement Storm Door 2 Lite Casement Window Capping &,1A17 3 Lite Casement Mullion Remo Awning Screens r5 Hal / Full Basement Hopper Colonial Grids Z�'S Wood / Steel Bay Window Metal Window Conversion 30-De ret / .45-Degree ADDITIONAL NOTES / � �� if 6(-j17S a v' � b!/J � � � 0.FYI le I e ` -e xL / 14 a t� •e„ '�L� '�!� �' ryt Homeowners' Initials My ame Representative's Initials MY 140ME CONTRACTING,LLC f � y t Registered In Massachusetts&New Hampshire P-O.Box 989 * Methuen,MA * 01844 " Tel((978)682-9052 MEMBER P.O.Box 144 * Deerfield,NH * 03037 Tel. (603)463-8898 Toll Fr6e(800)921-9052 " Pax(603)463-8911 www.myhomewntrac,ting.com 7 job ..•:�.wm..�•Tv.Y.•Lr..+M,MHe•I.TeM tiwmwvrasa�.sy.nnr.bn�-IAn.�•4Ya•.�•�•�.wn.mea+•arm.msv.Au�hWld�a'Ua,ava•rveu�.V�c JnSwutrvxoxmon•rov�:.wyw.wo-..-w.•aura.wwraw-.nie�.�hM�•�nrus,.i..w.�eavrnas:N3e e 74 INVESTMENT TOTAL FOR SPECIFIED PROJECT WE HEREBY PROPOSE TO FURNISH ALL LABOR AND MATERIALS IN z ACCORDANCE WITH THE ABOVE SPECIFICATIONS r FOR THE SUM OF Rp �1arc,>axnwv.• u,acr..S:nwner.�..wnPSty-w.+.••.,..,�w,•>mroJ.r.,1wa»tvw•^•••�••••••.•uow.u.r..e,aq:,..w�a...-.s,..a.x.•n...�s,:.vww�,uer.•uct+vwJaf�set✓C�+�M�n.wmewvn�[avaWev4Hwah�'a.an�+aa�vtA',�'Y�bw'�� Deposit Payment Options Deposit $ i Cash Visa MasterCard Deposit Due on Re-measure $ � Acct.iE Exp.Date Balance Due On Completion $ -��Z Indicate payment method for -� Name as k alb on card: Balance Due On Completi g 7 By mylour signature below,We agree to allow My Home Contracting,I.LG to charge the above rdereneed credit card for the amount indicated above. Check Credit Card f=inance Cardholder's Signature Date Signature of My HomCo r epresentative: Authorized Signature: ' date: ���� Authorized Signature: Date:IV -- MY HOME CONTRACTTNG, LLC �C e Registered In Massachusem&New Hampshire #, f ` P_O. Box 989 * Methuen,MA * 01844 Tel.(978)682-9052 MEIN UR P.O. Box 144 * Deerfield,NH * 03037 * Tel, (603)463-8898 Toll Free(800)921-9052 Fax(603)463-8911 wwwmy homecontracting.com 4 CGI/CO 730HJ nklT Ir1HU 1 1,InI-1 71.IrlU A rrrrnn�nnn ._�•.... ..-..� •-� ..-..