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HomeMy WebLinkAboutBuilding Permit #221 - 259 GRANVILLE LANE 9/18/2012 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued: y _ _ IMPORTANT:Applicant must complete all items on this page `I LQCATION Z � %I�thVv� I11Fg1� _ - _ f Print; PROPERTY OWNER_ Print'. 100Ye6r01d Structure yesen MAP N©- Q ARCEL: ONING DISTIRICT; - Histonc0istrict yes, : Machine;Shop Village.! yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition N% l wo or more family ❑ Industrial DIAlteration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: _ ❑ emolition ❑ Other Septic ❑Well' 0;F1oo01aln? ❑Wetlands ❑ Watershed'District ❑Water/Sewer -- DESCRIPTION OF WORK TO BE PERFORMED: a detification Please Type or Print Clearly) OWNER: Name: ,T Phone: Address: 67rany(IL Law CONTRACTOR Name: Address: Supervis-or!s,Construction Licenser -7y.57,;)_ Exp'., Date:. , a 6 _ Date: CS a HomefImprovement License;. d 1 o Ex p: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT $12.00 PER$1000.00 OF THE TOTAL ESTIMATED�T BASED ON$125.00 PER S.F. Total Project Cost: $ 9�r` �5 FEE: $ 3a 22� �D Recei t No.: Check No.: p NOTE: Persons contracting 'h un gisterarc do not have access to the guarantyfund nature-of Agre ofcontract r Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION .Z Jf�v ��Y'Cl(�VI lltP �4Y��Q _ Pnntt (� r PROPERTY/OWNER, — l"1 F- L,.auasS _n_ _ E- -11 - - Print, 100Year,0ld Struc MP NOture ' yes. no A ' ARCEL: 0NING DISiTRICT: H,istoric,District yes no. . / Machine Shop Village, yes no TYPE OF IMPROVEMENT PROPOSED USE R idential Non- Residential ❑ New Building One family ❑Addition ❑ wo or more family El Industrial ❑ Iteration No. of units: ❑ Commercial epair, replacement ElAssessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic []Well. 0 Wetlands. ❑ WatershedDistrict, 0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: <klk" (A detification Please Type or Print Clearly) OWNER: Name: � La-(Irocs- Phone: Address: C-7rany(lif LOJM - II CONTRACTOR Name: __ 0VfY1t rr,ett'b Phone: . i Address: b3g`F. ' _ r p' Supervisors Construction License: wTy.J�� Ex . Date:. Improvement 6014LI ExP Date: L S ARCH ITECT/ENGINEERPhone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT-$12.00 PER$1000.00 OF THE TOTAL ESTIMATEDJCT BASED ON$125.00 PER S.F. 9FEE: � 1/14. Total Project Cost: $ l 1Receipt Check No.: 122$ No.: NOTE: Persons contracting%0hunister r e ors do not have access to the guaranty fund Sig:riature of Agent/OwnerT tur of'contract Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Location N Date o y TOWN OF NORTH ANDOVER 0 ��•t�11 CSD:��9�`. . e y Certificate of Occupancy $ Building/Frame Permit Fee $ 00 r �r Foundation Permit Fee Other Permit Fee $ �' TOTAL $ Check#I1 25727 uilding Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature C CO61MENTS 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 yeas no Located at:124.Main'�Street Fire Department signatute7date ` COMMENTS Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food g Packag in /Sales El Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature C COMMENTS 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 Strdet 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 Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$10041000 fine NOTES and DATA— (For department use i r � ® Notified for pickup - Date f Doc.Building Permit Revised 2010 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 Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes filo MGL Chapter 166 Section 21A—F and G min.$10041000 fine NOTES and DATA— (For department use I El Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department The following is a list of the required forms to be filled 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 NOTE: 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) o Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application j ❑ 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 j NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit I In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals 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: Doc.Building Permit Revised 2012 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit o 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 NOTE: 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 NOTE: 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) o Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals 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: Doc.Building Permit Revised 2012 I J r 'i ' NORTH - w. - ver p �+ 1 No. oh ver, Mass, COC NICKIWICK A�RAreo S U BOARD OF HEALTH PERM T LD Food/Kitchen Septic System THIS CERTIFIES THAT ®. ..... .,,. ... �0. BUILDING INSPECTOR ...................... ............. .... ............ ............. Foundation has permission to erect .......................... buildings on .... .... .... ... ... ......... Rough to be occupied as ................ ....... .o ......................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough pp Final PERMIT EXPIRES .IN 6 IVIO THS _ ELECTRICAL INSPECTOR UNLESS CONSTRUCTIONS Rough C Service ....... ..... ........................ .......... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business!organization/Individual): Kevin CAfr!e1� Address:- 1��5 fid• —.__ —_—___. _ i City/State/Zip: Phone#: d l' 3� X70( 11- Ar you an employer'.'Ch the appropriate box: Type of project(required): i am a employer with a 4. F-1 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction I am a sole proprietor or partner- listed on the attached sheet. 7. E] Remodeling I ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. F1 Building addition [No workers' comp. insurance comp.insurance.- 5. required.] ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.0 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. (No workers'comp. right of exemption per MGI, 12.0 Roof repairs insurance required.1 '' c. 152.§1(4),and we have no employees. [No workers' 13.0 Other ----- comp.insurance required.) Any applicant that checks box a t must also fill out the section below shoeing their workers'compensation policy information. Iionteo%%ners tt ho submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. -Contractors that check thi<box must attached an additional sheet shoving the name of the sub-contractors and state whether or not those entities have employees. i I'the sub-contractors have employees.they must provide their workers comp.policy number. I am an employer that is providing workers'compensation insurance for my emplovees. Below is the policy and job site information. Insurance Company Name: �•li�1Q o �DU J (-Q I' �InS, —_ Pofic) =or Self-ins. Lic. KO B- e311 FV- – 0 Expiration Date: 2- Job Site Address:__ s_q V 1 City/State/Zip: Llaic& 01# Attach a copy of the workers'compensation policy declaration page(showing the lie number and ex po Ypi tion date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine 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 tine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office o1' investigations of the DIA for insurance coverage ver' ation. I do hereby cern,-tend epai, a en t all e r oration provided a ve is Ir a and correct. Si��nature: Date: /7 Phone= �7 D.. ---- ---- - 3 — Official use on/r. Do not write in this area,to be completed by city or town official 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#: 9 .F x >3 dVt a�chc setts t7epartm nt;of i' Wit Sa z 8utiegulations and Stas�c€ar s a�rsatructir n SUPen im .072 . KEialN C CARREjt afi +t�l.5�rv� s{��+4.( ,�yr ■ y � �/t3x.*}x �..,. k'"v 1 �{ .'�B YM� w�+�i Tn}l YY/021261.4 Ai &' LRP.�._ fi7 ✓ Win; - ��-74eo4lp'�,G x5 xS.dR' 4 MS., S. R O1�U/?LC�/LClfeCLL���dC�'r���CGr.�LCCiI�t� .tr�' i ffice of Consumer Affa►t &2 us esus Regi itii i _1Id�r3�M RQVEMEM�f GQYN U4G�i pR 0 QV a. �,�3�`'� s-�„�'� ,r���1 '�r �yy�' ' ,fit •€��;y��`" x I STORE COPY INSTALLATION SERVICES CUSTOMER CONTRACT- MWORK- INT/EXT/PATIO DOOR LOWE'S OF SALEM, NH, STORE#2382 STORE PHONE: (603)681-4218 541 SOUTH BROADWAY SALESPERSON:ANTHONY CORNACCHIO - -- SALEM, NH 03079-0000 SALESPERSON ID:631180 Document Print Date : 08/29/2012 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- 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, Inc.'s MA HIC NO.: 148688 Lowe's Home Centers, Inc.'s FEIN: 56-0748358 Customer Name Home Phone S ERIK LACROSS 978-208-7804 O Customer Address Other Phone 259 GRANVILLE LN L City State/Province Zip/Postal Code D NORTH ANDOVER MA 01845 Installation Address T 259 GRANVILLE LN O Installation City Installation State/Province Installation Zip/Postal Code NORTH ANDOVER MA 01845 MERCHANDISE AND INSTALLATION SUMMARY MERCHANDISE SUMMARY 67465 : 5/4 X 10 X 20FT PVC : SOS : SOS BROSCO ENTRY DOOR : WHITE PVC BOARD BY KOMA : BROCKWAY-SMITH COMPANY - QTY 1 67465 : B-6 : SOS : SOS BROSCO ENTRY DOOR : 3' PILASTER FLUTED KIT W PLINTHS 5 1/2" X 610" WHITE PVC INTEX : BROCKWAY-SMITH COM- PANY - QTY 1 67465 : B-3D : SOS : SOS BROSCO ENTRY DOOR : DENTIL HEAD 3'0"WHITE PVC INTEX : BROCKWAY-SMITH COMPANY - QTY 1 12192 : STK : 15/32"X4X8 3 PLY SHTG 32/16 : 15/32"X4X8 3 PLY SHTG 32/16 - QTY 1 30906 : 30906 : STK : 2X6X8 ACQ TOP CHOICE TREATED : 2X6X8 ACQ TOP CHOICE TREATED : POLLARD LUMBER - QTY 2 43393 : 26SE.14 : STK : 2X10X8 TOP CHOICE KD WHITEWOOD : 2X10X8 TOP CHOICE KD WHITEWOOD : CANFOR WOOD PRODUCTS MARKETING - QTY 2 Store 2382 Project No. 361032906 for ERIK LACROSS Page 1 of 8 t STORE COPY 65097 : 90976 : STK : PEL 36-IN MONTGOMERY WHT BR FV : PEL 36-IN MONTGOMERY WHT BR FV : CLO LARSON MANUFACTURING COMPA - QTY 1 238348 : 2828-8 : STK : 3/4X7.25X8 RF EMBOSD PVC TRM BRD : 3/4X7.25X8 RF EMBOSD PVC TRM BRD : ROYAL MOULDINGS LIMITED - QTY 1 39683 : PRODUCTCODE : SOS : SOS RB COMMODITY FBRGLS-DORFAB TC : ENTRY/EXTERIOR SINGLE UNIT, 6 PANEL : DOOR FABRICATION SER- VICES, INC - QTY 1 Materials Price $ 1030.95 INSTALLATION DESCRIPTION Stock or SOS : Stock Door Type : Exterior Select Location : Front Door Select New Door : Single Pre-hung Number of Doors to Install : 1 Side Lights or Transoms : No Hardwood (Mahogany or Oak) Door : No Hidden Damage Description : rot Hidden Damage Charge : Yes Number of additional holes bored for accessories : None Install Specialized Mortise Hardware : No Install Storm Door : Install new storm door Select Storm Door : Storm Door Lead Safe Practices : No Total Linear Feet of Custom Trim to be Installed : 40 Deliver Door: Yes Customer Understands Scope of the Project : Yes Permit Required : Yes Who Will Obtain Permit : Lowe's Permit Fee : No Additional Miles Traveled over 20 : 0 Bring Up To Code Description : None Local Disposal Fee : Yes Describe Other Work Needed : trim Other Work Charge : Yes Comments : cust will select doors later Labor Charges $ 953.50 Detail Deduction -$ 35.0 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. Store 2382 Project No. 361032906 for ERIK LACROSS Page 2 of 8 r• STORE COPY TOTAL CHARGES OF ALL MERCHANDISE AND SERVICES where applicable SUB-TOTAL A194 . *TAX DELIVERY ORDER TOTAL $ 1949.4 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 pay in full COMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS $1,000.00: [_] Customer to Pay in Full; OR [_] Customer to use the following payment schedule: (1) Deposit$ to be paid upon signing contract. Deposit should be 1/3 the total contract 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 indicated above 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 BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND CONDITIONS CON- Store 2382 Project No. 361032906 for ERIK LACROSS Page 3 of 8 4 STORE COPY 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 EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUB- MIT TO SUCH ARBITRATION AS PROVIDED IN M.G.L. c.142A. By: Date: Lowe's Home Centers Inc. By: Date: Owner By: Date: S ouse THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED BY LOWE'S PURSUANT TO M.G.L. c. 42A. 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 DAY OF Lowe's Home Centers, Inc. By: (Seal) Print Name: Address (Seal) Owner City State/Province Zip/Postal Code f �~ Print Name Co-Owner or Witness (Seal) Store 2382 Project No. 361032906 for ERIK LACROSS Page 4 of 8