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HomeMy WebLinkAboutBuilding Permit #211-14 - 547 MASSACHUSETTS AVENUE 9/6/2013 i TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: �Z// Date Received Date Issued: G IMPORTANT:Applicant must complete all items on this page U , LOCATION` PROPERTY 0WNERJQ6 S - — - - Print 100 Year Old.Structure yes no MAP NO:=/,y__ PARCEL: ZONING DISTRICT: Historic District yes no -Machine.Shop.Village yes. no TYPE OF IMPROVEMENT PROPOSED USE Resideal Non- Residential ❑ New Building he family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic ❑Well ❑ Floodplain ❑Wetlands El Watershed District ❑Water/Sewer.. DESCRIPTION OF WORK TO BE PERFORMED: ?e)o Ictet�ifiea 'on Pe or Print Clearly) Phone: ` Z�✓��� � � OWNER: Name: (� Address: /%GU7 456 f ©h% _ _ _ Phone:,_ ' CONTRACTOR, Na".: - A - Address:., - \:K37 PLels Supervisor's,Consttucton License: , (� - - Expo Date _ . Home Improvement License,: �D.�. � -_ _ . Exp. Date: 7 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PE*IT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ �(��®� FEE: $ S�D� Check No.: �fG Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund S natureofAgent/Owner Sigpature:of_contractor, ,� _ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ i Building Department The fol 13 1 is a list of the required.forms to be filled out for the appropriate permit to be obtained. I Roofivg, 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 o 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 pp 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 o Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract o Mass check Energy Compliance Report o 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 apw al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Building Permit Revised 2012 J Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYP ­OF:SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑. . _Swimming Pools ❑ Well ❑, Tobacco.Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc.. Permanent Dempster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED: DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS i CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments @i1/c ier & Sewer Connection/Signature & Date Driveway Permit DPW Toes Engineer: Signature: Locate 384 sq ood Street FIRE-DEPARTMENT -Temp Dumpste_r on site yes no -Located-at 124.Mair, Street :.�. -Fire Departmerit•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.$100-$1000 fine NOTES and DATA— (For department use � I i i D Notified foricku - Date P p I � Doc.Building Permit Revised 2010 Location �y 7 /x��GSfy f. No. - y Date ® - TOWN OF NORTH ANDOVER e o Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ �r 4rro NN ' TOTAL $ Check# �/ 26816 Bufil ing Inspector NORTH own of ? E : .�. . ndover o - :� 0% No. ti L/1N. h , ver, Mass, X1/3 COC NIC NlWKu �1' �.9 A°R^rEo ►�P�,��S S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System M �/ /,/( BUILDING INSPECTOR THIS CERTIFIES THAT ................. v "� has permission to erect buildings on ,; -SSL Foundation Rough tobe occupied as .......................(x4.. .............................................................................. 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 Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough Service ............... ....... + C: ::,,�.,.........INSP................ Final BUILDING ECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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 4. I� Department of Industrial Accidents s " Office of Investigations I r: 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/ +lectricians/Plaunbers )plicant Information Please Print LMibl� line (Business/Organization/Individual): [dress: f�L' 51�T Sr y/State/Zip: G�! Phone you an employer?Check the appropriate box: Type of project(required): am a employer with 4. ❑ I am a general contractor and I employees(Rill 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. ❑ Remodeling ship and have no employees These sub-contractors have 8. F1 Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.t 9. EJ Building addition required.] 5. ❑ We are a corporation and its 10.E]Electrical repairs or additions I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12 oof repairs insurance required.] i c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] )plicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. owners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ctors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have .es. If the sub-contractors have employees,they must provide their workers'comp.policy number. w employer that is providing workers'compensation insurance for my employees. Below is the policy and job site cation. / nce Company Name:. 17 F /09UrU1`z_1 CGt/S 6 0 #or Self-ins.Lic.#: 761/4(6 1fY0/CZ 00 Expiration Date: to Address: 19VP' f ld /V//�do t,/State/Zip: M)9 C'A�`l, a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 o$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of gations of the DIA for insurance coverage verification. weby certif�dthepains annddpenaalties ofperjury that the information provided above is true and correct. ,ire: � %� 4%�C Y� Date: r-- Wal use only. Do not write in this area,to be completed by city or town official or Town: Permit/License# ting Authority(circle one): .oard of health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector >ther itnet P.rcnn- Phone#r I � I Massachusetts -mac, ffinent oir Beard of Bwld nq ! fi;l^ICY".R c:`'a+slt slw i4:.` , c r'se: CS-022680 ARTHUR J WALSH JR1 159A WAVERLY-RD N ANDOVER MA 01845, at _. 06/09/2014 Office of Consumer Afflirs&Busless Regulntio�n /.. = .}i0ME IMPROVEMENT CONTRACTOR kegistration: 103358 a;MQ Type: Expiration: 7/7/2014 Private Corporatir• A•J\WALSH&SONS,INC. Arthur Walsh,Jr. 55 Pleasant St N Andover,MA 01845 ��— Undersecretary ur—M 1 IrlliN I G %JF LIM®11-1 1 1 OIMI12013 ..ice IIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS ;RTIFiCATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES :LOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTHUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED WRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. !PORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy(ies)must be endorsed. If SUBROGATION IS WAIVED,Subject to e terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer right$to the irtificate holder In lieu of such endorsement(s). LACER 00775-001 So&Jankowski Insurance (Ida E1rt1: (978)sa2-6176 ll .No: (998)794-0313 _ Mass Ave Suits 1018 ��I#>ss - — th Andover,MA 01845 - rHsuarggf�pFOrI,QIdsILS�OY�ca -- IN A.I.M.(AR)Mutual Insurance Company 33758 ZED I>Dl9tlR66J3i—_. - ---- Iur walsh INSJJt3E�ciJ__.. I Walsh&Sons — PleasarltStreet •- — _ th Andover.MA 01845 g s; jKH%JIRFR F! VERAGES CERTIFICATE NUMBER: REVISION NUMBER, JIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD DICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS ^RTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, ZELUS10NS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, _ M �SY! - ADDL LIMITS TYPO OF INSURANCE INBR POLICY NUMHER ... ---- _ .. GENERAL UAMUTY EACH OCCURRENCE S _ DAMA E Ta RENTED COMMERCIAL GENERAL LIABILITY geSaAoc2rrrenoo)_-•.$Y — CLAIMS-MADE 0 OCCUR MED EXP(Any QM pereon) S __ PERSONAL&ADV INJURY S _ - GENERAL AGGREGATE — s EN'L AGGREGATE LIMIT APPLIE8 PER; PRpouCTs-COMPlOP AGG S OLICY l JILT I �OG --- --- _ -- --. - COMBINED sIN�iLELIMiT AUTOMDHILELIABILITY (EeecadeN) S- -' ANY AUTO BODILY INJURY(Per person) S ALLCU70SMED SC AUTOSULeD BODILY INJURY(Per acc�daM) S — - -' NON OInNEo -PROPS RTYDAMAOE _ HIRED AUTOS AUTOS (Pea= — 3 UMBRELLA LIA9 OCCUR _ EACH OCCURRENCE $ _ CLAIMS MADE AGGREGATE S -- Ex Like _ CEEB DED RETENTION$ w $ yy�R EQpSg��pQM�qppE�NNggppT�tDpN� x AND�RM�I'p1AR�YEETRQ3�'/L�IAHYIUNETYq/EXE L.LN, E. EACH ACCIDENT S _ 100,000 a� 1cER1N1EMBER ExGIUDED�-CUTiVE�„ i NIA AWC7014648012012 11!1412012 11/1412013 fi L,DiSEA8E-EA EMPLOYEE 3 _ 100,000 (Mandatory In NH) - - ��g� ( i DF OPERATIONS below T D kASE.POLICY LVM1Y 5 600,000 NCRIPTION or OPERATIONS r LoCATIONB I VEHICLES(Attach ACORD 101,Additional Remarks$Module,tt more splice Is required) lERTIF CATE HOLDER CANCELLATION 'own of North Andover 600 Osgood Street THE U P�XPIRATiOHH DATE ABOVE DESCRIBED NOncE I WILL BE DEL VED BEFOREIN forth Andover,MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ®1 88.2010 ACORD CORPORATION-All rights reserved. LCORD 25(2010105) The ACORD name and logo are registered marks of ACORD �l 'd ILZL 'ON : 30NUASNI 03iVI00SSd Wdll )� eIOZ 'l l UP MASSACHUSETTS HOME IMPROVEMENT CONTRACT This form satisfiesall basicrequirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standtird language to protect homeowners. Seek legal advice If necessary.-Any personplanning home illttnprov I ... should first obtain a copy of"a Massachusettseonsumergnidexohome improvement"beforo agreeing.toany work on yourresidence;You may obtain>a free copy by'calling the' Office of Consumer.:Affairs and Business Regulation's Consumer Information Hotline at617-9738787 or 1..88&2834757. . Homeowner Information Contractor Inforlmation f nine -.... . •. PmY Name ' Street Address(do not usaafost Office Box address) tierter/Salrspaaon/.Oxmer Name ASS . 4,'tfli Vii? . �L S - Cityrrown state Zip Code hasiness Address(must include a street addresy) . Daytime Phone Eveningph '. ryf7own State Zip Code Mailing Address(It different from above) 3usiness Phone ederal Employer M or S.S.Number �j U-ftQ,dp,tmlmaotmmaim. Roma tC®aadoraea Thmbet�ExPuuim0e . pvvmmt oontnprvee I t y�/�/ . n;im,aoa oambrr yQ ��t, The Contractor agrees to Homeo ne_r.do the following work for the �J 4T lie uiredPe rmlfa-The followin building' ... 9 g ng permits are required Proposed Start and�'Completlon Schedule-The following schedule will and will be secured by the contractor as the'homeowner's agent; be adheredtotinlass circumstances beyond the contractor's control arise (Owners who•secure their own permits will be excluded:from,theGuaranty Fund,provisionsof _1y�� —. atewitchcontractorwillbegincontactedwork. MGL chapter 142A.) ` when, — — contracted work will be substantially eompleted. Total Contract Price and PaymentSchedule The Coatraetor.agrees to perform the work,furnish the material and tabor specified above for the total sum of. _dPayments will be atade according to the following schedule: $3,7tJ6, 1 Upon siSsighingcontract(not to ex ceed 1/3 of the total:contract price,4[the cost;of special order Items,whichever ister. 8� ) $ by=/P'T or upon completion of by / / or upon completion of o F $ / upon completion of the contract (Law forbids demanding full payment until.contract is completed to both Party's satisfaction) The following material/equipment must be special Sebe paid for ordered before the contacted d work'begins in'order 5_to be paid for to'meet:tlie,completion schedule.(••) NOTES:(•)lnriuding all finance charges(••)Iaw requires that my deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special.equipment or custom made material which must be special ordered in advance to meet the completion srbedule. Express Warranty Is an express wamoty barn¢provided by theyontrra.r..n No Yes .(all terms of the ped to the eoptnetl Subcontractors The contractor agrees to be solely responsible for completion of the work desced regardless of the actions of any diiid patty/subcontractor utilized by the contractor. The contractor further agrees to be solely nbresponsible for all payments to all subcontractors for materials and Is under ibis a•TMt errant Contract Acceptance Upon signing,this document becomes a binding.contract under:law. Unless otherwise noted within this document the contract sbnot imply that any lien or other security intera0-been placed on the residence. Review the following cautions and notices carefully before signing this contract • Doul be pressured into signing the contract Take time to tead'and fully understand it. Ask'questioru ffsomething is unclear. • Make sure the contractor has a valid Nome Improvement f pntrnr n pe,l The I&requires most borne improvement contractors and. subcontractors m be registered with the Director ofHome Improvement Contractor Regishation. You may registration by writing to the Director at One Ashburton Place,Room 1301,.Bos mqu�atractor, 1-800.223-0933. to4'MA 02108 orby.ealli ng 617-7277-3200-3200 reor . • Does the contractor have insurance? Check to see that your contractor is properly insured. • Know your rights and responsibilities. Read the Important Inf rrmitdoa on flue itvt raeside of tliis form and get a copy of the Consumer Guide to the Home intprovement Contractor law: You rosy cancel this agreement if it has been signed at a place other than the contractor's'normal lace of business,provided contractor fn writing at his/her meta ole or branch office by ordinary mail posted tele P P You notify the third business da followin Ute si by 8r�sent or by delivery,not later than midnight of the, Y g. gning of this agreement.See the attached notice of cancellation form for an explanation of.this right DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! coo identical eepim of the contract must be eozopleted and maned One copy.abould W to dm Inarawner.The other. - ,�cDY�altouW be kept by the contractor. Homeowner's i m '�/f/ •�� Contractor's Signature 7 nate :Date Contractor Arbitration . The Home Improvement Contractor Law provides;homeowners with:thenglivto4nitiate an arbitration action(as an altema W to court ac40)if.they.have a_dispute;with a contractor. The same right.is not automatically afforded to a. contractor,how.ever..The contractor would have:tp resolve any,dispute'he/she.ltas with a homeowner in court unless .._. both parties agree to,the optional eiauseprovided below:.This clause would.give the contractor same.right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute - concerning this contract,the contractor may submit the dispute to a.private arbitration firm which hog been.approved by. the Secietary of the Executive Office of Consumet Affairs 4fid Business Regulation and the consumer shall be lequireil. to ubniit to such arbi n as p vided In•Massachusetts General Laws,chapt 42A. Homeowner's Signiltu Contractor's Signature NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor.i The homeowner,may initiate alternative:dispute resolution even where this section;is not separately signed by':the parties-. Homeowner's Rights A homeowner's rights undia tho Iome'Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement: However,homeowner; may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The-contractor is responstble-for completing the work as described,in a timely and;workInplike manner. Homeowners.may be entitled to.other specific legal:rights if the contractor guarantees. or provides an.express warranty for:workmanship or materials. In addition to.guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability:and.fihiesi,foi:a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree;may be added:to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your : nsumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in_d_uplicate and should not be signed until a copy of all exhibits and referenced documents have been attached Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification.to the griginal contract must be in writing and agreed to by both parties.Contracted Work may not begin until both parties have received a fully executed copy of the contract,and the three day recission period has expired Accelerated Payments A contractor may not demand payments inadvance.of thedates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to.continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or.need additional information about the Home Improvement-Contractor Law.or other consumer rights;.or if you wisb to:.obtain a.&.w'copy of"A Consumer Guide to the Home.Improvement Contractor Law, contact .. . Cgnsutner Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 (617)973-8787 or 1-(888)2833757 If you want to verify theregistration of a contractor or if you have questions or need:additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Bureau of Building Regulations and Standards One Ashburton Place,Room 1301,Boston,MA 02108 . T (617)727-3200 ort-800-223-0933 For assistance with informal mediation'of"disputes or to register formal complaints against abasiness,'call: Consiiiif et^Coiaplaint'Section Office of the Attorney General (617)727-8400 AND/OR Better Business Bureau (508)652-4800 (508)755-2548 (413)734-3114 Propool Page# of pages CS # 022680 978-688-6737 HIC# 103358 A. J. Walsh & Sons or 55 Pleasant Street 1-866-AJWALSH .North Andover, MA 01845 Proposal Submitted To: Job Name Job# Address ' Job Location s� 17 Date � �� � Date of Plans Phone# 7 t � </ ,5' Fax# f Architect We hereby submit speci#ications and estimates for. 121 7,R Wepropose hereby to fumish material and/labor—complete in accordance with the above specifications for the sum of: l Dollars with payments to be made as follows: V fI Any alteration or deviation from above specifications involving extra costs will be Respectfullyl executed only upon mitten order, and will become an extra charge over and above the estimate.Alla agreements contingent submitted g ge upon strikes,accidents,or delays r beyond our cdhtrol. Note—this proposal may be withdrawn by us if not accepted within days. ZIcceptance of j)r0p F al The above prices,specifications and conditions are satisfactory and are '`Signature V C hereby accepted.You are authorized to do the work as specified. Payments will be made as outlined above. Date of Acceptance Signature