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HomeMy WebLinkAbout580 W Airport Blvd; 11-1871; ELECTRICALF; CITY OF SANFORD BUILDING & FIRE PREVENTION PERMIT APPLICATION Application No: / ! Documented Construction Value: $ flWFL 3a-113 oyJob Address: j +Historic District: Yes No Parcel ID: 6L — aQ0 tsQ) QM 6©OCR Zoning: Description of Work: Plan Review Contact Person: Phone: Fax: E- mail: Title: r Property Owner Information Name AFH . T . oc\& \\C. Phone: Street: 13j e Z\\Jd Resident of property? City, State Zip: 1,.,k TX :2 b01la Name N 1D T Contractor Information Street: G% 3 aM City, State Zip: a Name: Street: City, St, Zip: Bonding Company: Address: Phone: Fax: State License No.: E'F QQ O 1Va-\ Architect/Engineer Information Phone: Fax: E- mail: Mortgage Lender: Address: PERMIT INFORMATION Building Permit Square Footage: 10 Construction Type No. of Dwelling Units: Flood Zone: Electrical COY' New Service — No. of AMPS: Mechanical 11 (Duct layout required for new systems) No. of Stories: Plumbing New Construction - No. of Fixtures: Fire Sprinkler/Alarm No. of heads: Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for electrical work, plumbing, signs, wells, pools, furnaces, boilers, heaters, tanks, and air conditioners, etc. OWNER'S AFFIDAVIT: I certify that all of the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT. NOTICE: In addition to the requirements of this permit, there may be additional restrictions applicable to this property that may be found in the public records of this county, and there may be additional permits required from other governmental entities such as water management districts, state agencies, or federal agencies. Acceptance of permit is verification that I will notify the owner of the property of the requirements of Florida Lien Law, FS 713. The City of Sanford requires. payment of a plan review fee. A copy of the executed contract is required in order to calculate a plan review charge. If the executed contract is not submitted, we reserve the right to calculate the plan review fee based on past permit activity levels. Should calculated charges exceed the documented construction value when the executed contract is submitted, credit will be applied to your permit fees when the permit is released. Signature of Owner/Agent Date Owner/Agent's Name Signature of Notary -State of Florida Date Owner/Agent is Personally Known to Me or Produced ID Type of ID APPROVALS: ZONING: UTILITIES: ENGINEERING: COMMENTS: FIRE: Signature of Contracr ent ate 1 1 / 0•C' f l Printl ontraJt r/Agent's Name Signature o ota Rtate of Flnrirla Y ASHLEY AMMONS MY COMMISSION; DG89Wj Q°" EXPIRES: May 27, 2013 of e? Bonded Thru Notary Public Underwriters Contractor/Agent is Personally Known to Me or Produced ID Type of ID WASTE WATER: BUILDING: Rev 11.08 POWER OF ATTORNEY Date: 77 1911 I hereby name and appoint V) r& of ADT Security Services to drop off and pick up permits at the SG,R J'0(-A -Building Department on my behalf for a LOW VOLTAGE SECURITY permit for work to be performed at a location described as: Parcel-0 _c), aQ 30— 03R E - Subdivision Address of job Owner m 11 V — George Manginelli EF0001121 Type or Print Name of Certified Contractor Signature of rhfi Contractor The for oing instrame t was ackaowl ged before me this J '6 day of 20 l byAll- who rsonall known to me who produced as identification and who did not take oath. State of Florida GP County of Notary P Seminole County, Florida S SPAY p t five E 'YA,"VONS L 34,1 -7 3 Seminole County Property Appraiser Get Information by Parcel Number Page 1 of 4 Personal Property 1 Please Select Account y n(k DAYin JOHNSON, CPA, ASA PROPERTY APPRAISER SEMINOLE COUNTY FL. N e 1101 E. FIRST ST SANFORO, FL3277t-146a 407 - 665 - 7506 VALUE SUMMARY 2011 2010 VALUES Working Certified Value Method Income Income GENERAL Number of Buildings 21 21 Parcel Id: 02-20-30-300-038E-0000 Depreciated Bldg Value 0 0 Owner: AHF-BAY FUND LLC Depreciated EXFT Value 0 0 Mailing Address: 1310 N WHITE CHAPEL BLVD Land Value (Market) 0 0 City,State,ZipCode: SOUTHLAKE TX 76092 Land Value Ag 0 0PropertyAddress: 480 AIRPORT BLVD W SANFORD 32771 Just/Markef_V_alue 6,001,528 ` 5,988,039 ` Facility Name: VILLAGE LAKES Portablity Adj 0 0TaxDistrict: S1-SANFORD Save Our Homes Adj 0 0Exemptions: 43-AFFORDABLE HOUSING () Amendment 1 Adj 0 0Dor: 03-MULTI FAMILY 10 OR M Assessed Value (SOH) 6,001.528 " 5,988,039 Tax Estimator Income Approach used.) 2011 TAXABLE VALUE WORKING ESTIMATE Taxing Authority Assessment Value Exempt Values Taxable Value County General Fund 6,001,528 5.581,421 420.107 Amendment 1 adjustment is not applicable to school assessment) Schools 6,001,528 5,581,421 420.107 City Sanford 6,001,528 5,581,421 420.107 SJWM(Saint Johns Water Management) 6,001,528 5,581,421 420,107 County Bonds 6,001,5281 5,581,4211 420,107 The taxable values and taxes are calculated using the current years working values and the prior years approved millage rates. SALES Deed Date Book Page Amount Vac/Imp Qualified SPECIAL WARRANTY DEED 11/2005 06004 1571 $12,100,000 Improved Yes 2010 VALUE SUMMARY SPECIAL WARRANTY DEED 11/2000 03959 0651 $9,450,000 Improved No 2010 Tax Bill Amount: $15,637 CERTIFICATE OF TITLE 07/1996 03101 0127 $1,000 Improved No 2010 Certified Taxable Value and Taxes WARRANTY DEED 09/1986 01871 1118 $100 Vacant No DOES NOT INCLUDE NON -AD VALOREM ASSESSMENTS WARRANTY DEED 07/1986 01755 0415 $380,000 Vacant No WARRANTY DEED 07/1986 01755 Q412 $552,300 Vacant Yes Find Sales within this DOR Code LEGAL DESCRIPTION LAND LEG SEC 02 TWP 20S RGE 30E BEG 617,76 FT E & 701 36 FT N OF S 1/4 COR RUN E 274.86 FT ELY ON CURVE Land Assess Method Frontage Depth Land Units Unit Price Land Value 206 04 FT N 424.16 FT W 60 FT N 200 FT W 420 FT S 200 FT LOT 0 0 228.000 9,000 00 $2,052,000 W 382.57 FT N 75 DEG 24 MIN 29 SEC W 289.10 FT SWLY ON CURVE 188.72 FT S 20 DEG 13 SEC W 210 FT SELY ON CURVE 629 53 FT E 157 01 FT TO BEG (LESS RD) BUILDING INFORMATION Bid Num Bid Class Year Bit Fixtures Gross SF Stories Ext Wall Bid Value Est. Cost New Building 1 MULTIFAMILY 1987 24 8,490 2 STUCCO WITH WOOD OR METAL STUDS $390,189 $431,148 Sketch Subsection / Sgft OPEN PORCH FINISHED / 92 Subsection / Sqft OPEN PORCH FINISHED / 92 Subsection I Sgft OPEN PORCH FINISHED / 92 http://www. scpafl.org/web/re_web.seminole_coLinty_title?PARCEL=02203030003 8 E0000... 7/8/2011 Seminole County Property Appraiser Get Information by Parcel Number Page 2 of 4 Subsection I Sqft OPEN PORCH FINISHED / 92 Bui3 Idinn 2 MULTIFAMILY 1987 12 5,912 2 STUCCO WITH WOOD OR METAL STUDS $280,131 $309,537 Sketch Subsection I Sqft OPEN PORCH FINISHED / 124 Subsection I Sqft OPEN PORCH FINISHED / 124 Subsection / Sqft OPEN PORCH FINISHED / 124 Subsection / Sqft OPEN PORCH FINISHED / 124 Building 3 MULTIFAMILY 1987 12 5,912 2 STUCCO WITH WOOD OR METAL STUDS $280,131 $309,537 Sketch Subsection I Sqft OPEN PORCH FINISHED / 124 Subsection I Sqft OPEN PORCH FINISHED / 124 Subsection I Sqft OPEN PORCH FINISHED / 124 Subsection I Sqft OPEN PORCH FINISHED ! 124 Building 4 MULTIFAMILY 1987 18 10,320 2 STUCCO WITH WOOD OR METAL STUDS $462,430 $510,972 Sketch Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED 148 Subsection I Sqft OPEN PORCH FINISHED / 48 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 48 Subsection I Sqft OPEN PORCH FINISHED / 48 Building 5 MULTIFAMILY 1987 12 5,912 2 STUCCO WITH WOOD OR METAL STUDS $280,131 $309,537 Sketch Subsection / Sqft OPEN PORCH FINISHED / 124 Subsection I Sqft OPEN PORCH FINISHED / 124 Subsection / Sqft OPEN PORCH FINISHED / 124 Subsection / Sqft OPEN PORCH FINISHED / 124 Building 6 MULTIFAMILY 1987 24 13,236 2 STUCCO WITH WOOD OR METAL STUDS $585,122 $646,544 Sketch Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Building 7 MULTIFAMILY 1987 24 13,236 2 STUCCO WITH WOOD OR METAL STUDS $585,122 $646,544 Sketch Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Building Sketch 8 MULTIFAMILY 1987 12 5,912 2 STUCCO WITH WOOD OR METAL STUDS $280,131 $309,537 Subsection / Sqft OPEN PORCH FINISHED / 124 Subsection / Sqft OPEN PORCH FINISHED / 124 Subsection I Sqft OPEN PORCH FINISHED / 124 Subsection I Sqft OPEN PORCH FINISHED / 124 Buildin Sketch 9 MULTIFAMILY 1987 24 8,490 2 STUCCO WITH WOOD OR METAL STUDS $390,189 $431,148 Subsection I Sqft OPEN PORCH FINISHED / 92 Subsection / Sqft OPEN PORCH FINISHED / 92 Subsection I Sqft OPEN PORCH FINISHED / 92 Subsection / Sqft OPEN PORCH FINISHED / 92 Buildinguilding 10 MULTIFAMILY 1987 24 8,490 2 STUCCO WITH WOOD OR METAL STUDS $390,189 $431,148 Subsection / Sqft OPEN PORCH FINISHED / 92 http://www. scpafl.org/web/re_web.seminole_county_title?PARCEL=022030300038E0000... 7/8/2011 Seminole County Property Appraiser Get Information by Parcel Number Page 3 of 4 Subsection / Sqft OPEN PORCH FINISHED / 92 Subsection I Sqft OPEN PORCH FINISHED / 92 Subsection / Sqft OPEN PORCH FINISHED / 92 Building 11 MULTIFAMILY 1987 24 13,236 2 Ske..tch, Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Budding Sketch 12 MULTIFAMILY 1987 24 13,236 2 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED 1120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Building Sketch 13 MULTIFAMILY 1987 24 13,236 2 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Building 14 MULTIFAMILY 1987 24 13,236 2 Sketch Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Building 15 MULTIFAMILY 1987 24 13,236 2 Sketch Subsection / Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED 1120 Building Sketch 16 MULTIFAMILY 1987 24 13,236 2 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 STUCCO WITH WOOD OR METAL STUDS $585,122 $646,544 STUCCO WITH WOOD OR METAL STUDS $585,122 $646,544 STUCCO WITH WOOD OR METAL STUDS $585,122 $646,544 STUCCO WITH WOOD OR METAL STUDS $585,122 $646,544 STUCCO WITH WOOD OR METAL STUDS $585,122 $646,544 STUCCO WITH WOOD OR METAL STUDS $585.122 $646,544 http://www.sepafl.org/web/re_web.seminole county_title?PARCEL=022030300038E0000... 7/8/2011 Seminole County Property Appraiser Get Information by Parcel Number Page 4 of 4 Building Sketch 17 MULTIFAMILY 1987 24 13,236 Subsection / Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Building Sketch 18 MULTIFAMILY 1987 24 13,236 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection / Sqft OPEN PORCH FINISHED / 120 Subsection / Sgft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Subsection I Sqft OPEN PORCH FINISHED / 120 Building 19 MASONRY PILAS 1987 15 2,937Sketch Subsection I Sqft UTILITY UNFINISHED / 54 Subsection I Sqft OPEN PORCH FINISHED / 54 Subsection I Sqft OPEN PORCH FINISHED / 108 Building 20 WOOD BEAM/COL 1987 0 450 Sketch 21 WOOD BEAM/COL 1987 9 527 Subsection I Sqft OPEN PORCH FINISHED / 136 Permits 2 STUCCO WITH WOOD OR METAL STUDS $585,122 $646,544 2 STUCCO WITH WOOD OR METAL STUDS $585,122 $646,544 1 STUCCO WITH WOOD OR METAL STUDS $173,590 $239,434 1 STUCCO WITH WOOD OR METAL STUDS $16,927 $23,347 1 STUCCO WITH WOOD OR METAL STUDS $33,220 $45,821 EXTRA FEATURE Description Year Bit Units EXFT Value Est. Cost New COMMERCIAL ASPHALT DR 2 IN 1987 99,736 36,304 90,760 WALKS CONIC COMM 1987 6,786 8,985 22,462 10' CHAIN LINK FENCE 1987 200 800 2,000 4' CHAIN LINK FENCE 1987 160 256 640 TENNIS COURT/ASPHALT 1987 7,200 4,320 10,800 POLE LIGHT STEEL 1 ARM 1987 38 36,632 36,632 OVERRIDE 1987 1 10,000 10,000 BOAT DOCK 1987 400 800 2,000 POOL COMMERCIAL 1987 704 7,885 19,712 SPA 1987 1 2,200 5,500 WOOD DECK 1987 3,121 6,242 15,605 SAUNA/STEAM ROOM 1987 54 75,600 189,000 GAZEEBO 1987 448 896 2,240 NOTE: Assessed values shown are NOT certified values and therefore are subject to change before being finalized for ad valorem tax purposes. If you recently purchased a homesteaded orooerty vour next vear's orooertv tax will be based on Just/Market value. http://www.sepafl.org/web/re_web.seminole_county_title?PARCEL=02203030003 8E0000... 7/8/2011 RESIDENTIAL SERVICES CONTRACT IIII II IIIIIIIIIIIIIIIIIIIIIIIIIII II 5104UE12 II tCONTRACT/ j CUSTOMER ACCOUNT JNO m SO LEAD DATE U CEII f ! Section ADT Security Services, Inc. ("ADT') Office Address Customer, Name I ! f Customer" or "I" or "me" or "my") v I U 7777 11 11 1 1 1 11 111 r Address u / ! 1. bwo4 I I I T= city State I r I ZIP Tax Exempt No. Protected Premises' Telephone ? Tax Expire Date m/m O Traditional Phone O Other (Qualified) (D Other (Non -Qualified) WY ADT.com 1.800.ADT.ASAP® Alternate 1.800.238.2727) Telephone 1 1 O Home O Cell O Work IF FAMILIARIZATION PERIOD IS j AlternateTT REJECTED INITIAL HERE 9 / ; Telephone 2 O Home O Cell O Work see Paragraph 14 of the Terms and Conditions for explanation) ; EMAIL I Ab 114cl OMAAI, /16011111 Communications Authorization: I authorizeDT to provide me with information and updates about the security system and new ADT and third -party products and services to the contact inforrpa_ . provided by me. I may unsubscribe or opt out by emailing donotcontact@ADT.com or by calling 888.DNC4ADT (888.362.4238). Initial here Confirmation of Appointments: I authorize ADT to call me using an automated,callirig device to deliver a pre-recorded message to set/confirm appointments and provide other information and notices about.the alarm system at the telephone number(s) provided by me. Initial here Alarm System Ownership: O Customer -Owned @ADT-Owned I ACKNOWLEDGE AND AGREE TO EACH OF THE FOLLOWING: (A) THIS CONTRACT CONSISTS OF SIX (6) PAGES. BEFORE SIGNING THIS CONTRACT, I HAVE READ, UNDERSTAND AND AGREE TO EACH AND EVERY TERM OF THIS CONTRACT, INCLUDING BUT. NOT LIMITED TO PARAGRAPHS 5 AND 18 OF THE TERMS AND CONDITIONS. (B) THE INITIAL TERM OF THIS CONTRACT IS THREE (3) YEARS. (C) ADTVIS NOT A SECURITY CONSULTANT AND CANNOT ADDRESS ALL OF MY POTENTIAL SECURITY. NEEDS. ADT HAS EXPLAINED TO ME THE FULL RANGE OF EQUIPMENT AND SERVICES THAT ADT CAN PROVIDE ME. ADDITIONAL EQUIPMENT AND SERVICES OVER THOSE. IDENTIFIED IN THIS CONTRACT ARE AVAILABLE AND MAY BE PURCHASED FROM ADT AT AN ADDITIONAL COST TO ME. I HAVE SELECTED AND PURCHASED ONLY THE EQUIPMENT AND SERVICES IDENTIFIED IN THIS CONTRACT. (D) NO ALARM SYSTEM CAN PROVIDE COMPLETE PROTECTION OR GUARANTEE PREVENTION: OF LOSS OR INJURY. FIRES, FLOODS, BURGLARIES, ROBBERIES, MEDICAL PROBLEMS AND OTHER INCIDENTS ARE UNPREDICTABLE AND CANNOT ALWAYS BE DETECTED OR PREVENTED BY AN ALARM SYSTEM. HUMAN ERROR IS ALWAYS POSSIBLE, AND THE RESPONSE TIME OF POLICE, FIRE AND MEDICAL EMERGENCY PERSONNEL IS OUTSIDE THE CONTROL OF ADT. ADT MAY NOT RECEIVE ALARM SIGNALS IF COMMUNICATIONS OR POWER IS INTERRUPTED FOR ANY REASON. (E) ADT RECOMMENDS THAT I MANUALLY TEST THE ALARM SYSTEM MONTHLY AND ANY TIME I CHANGE TELEPHONE SERVICE, BY -CALLING 1.800.ADT.ASAP OR BY LOGGING IN TO WWW.MYADT.COM. (F) THIS CONTRACT REQUIRES FINAL APPROVAL BY AN ADT AUTHORIZED MANAGER BEFORE ADT MAY PROVIDE ANY EQUIPMENT OR SERVICES, AND IF APPROVAL IS DENIED, THEN THIS CONTRACT WILL BE TERMINATED, AND ADT'S ONLY OBLIGATION WILL BE TO NOTIFY ME OF SUCH TERMINATION AND REFUND ANY AMOUNTS I PAID IN ADVANCE. ADT Representative Name - Rep. License No. Rep. if Required) ID. No. Customer's Approval: Original Signature Required (Must match Customer Name in Section 1 above) NOTICE OF CANCELLATION I, THE CUSTOMER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OFCANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. I ACKNOWLEDGE BEING VERBALLY INFORMED OF MY RIGHT TO CANCEL AT THE TIME OF EXECUTION OF THIS CONTRACT AND RECEIPT OF THIS NOTICE. n- jli SerV ices toibe Provided FINANCIAL DISCLOSURE STATEMENT THERE IS NO FINANCE CHARGE OR COST OF CREDIT (0% APR) ASSOCIATED WITH THIS CONTRACT. A NUMBER OF . PAYMENTS FOR THE B. AMOUNT OF EACH PAYMENT IS $ TOTAL OF PAYMENTS FOR THE INITIAL TERM IS INITIAL TERM IS 36. (TOTAL MONTHLY SERVICE CHARGE FROM BELOW) (A• TIMES B.) (EXCLUSIVE OF ANY APPLICABLE A XES, FEES, FINE AND RATE INCREASES) LATE CHARGE - PAYMENT IS DUE PURSUANT TO MY SELECTED BILLING PREPAYMENT - IF I PREPAY THE SEE SECTIONS D FREQUENCY, PRIOR TO THE START OF SERVICE. MY FIRST BILL/CHARGE WILL BE SENT/MADE SHORTLY AFTER MY SERVICE BEGINS. ADT MAY IMPOSE A TOTAL OF PAYMENTS PRIOR TO 19 OF THIS CONTRACT FOR ONE- TIME LATE CHARGE ON EACH PAYMENT THAT IS MORE THAN TEN (10) THE END OF THE INITIAL TERM ADDITIONAL INFORMATION DAYS PAST DUE, UP TO THE MAXIMUM AMOUNT PERMITTED BY LAW, BUT IN OF THIS CONTRACT, THERE IS NO ABOUT NONPAYMENT, DEFAULT NO EVENT WILL THIS AMOUNT EXCEED $5.00. PENALTY OR REFUND. AND ACCELERATION. 1 - Of 6 Administrative Copy 02011 ADT. All rights reserved. (04/11) RESIDENTIAL SERVICES CONTRACT ii mniu r uii I CONTRACT % j CUSTOMER JOB LEAD DATE V ACCOUNT NO mNO SOURCE 74 ectioh'A. i • O Check received for: O Installation: Check # Amount O Annual Service Charges Collected: Check # Amount I authorize ADT O To withdraw all Service Charges from my bank account: ®To charge my credit/debit card for: O Annually OSerni-Annually O Quarterly O Monthly Installation O 3 monthly credit/debit card payments of equal amounts Choose one: O Checking O Savings (available only for telephone orders with an installation price over $400 or field sales with an installation price over $1,500) Name of Bank/Credit Union WAll/Recurring Service Charges O Annually O Semi -Annually O Quarterly Monthly ABA Routing Number Bank Account Number 4'VISA O MasterCard O Discover O AMEX Credit/Debit Card Number Expiration Date Recurring Service Charge Amount M M Y Y Name. as it appears on bank account Recurring Service Charge Amount Cardholder's Name I authorize ADT to debit my bank account for the amount of all Recurring Service Charges ! If I am using a debit card, I authorize ADT to debit my bank account for the amount of indicated above. I may revoke this authorization only by notifying ADT and my bank in all Recurring Service Charges indicated above. I may revoke this authorization only by writing at least 10 business days before the scheduled debit. notifying ADT and my bank in writing at least 10 business days before the scheduled debit. If no oval is filled above, service charges will be withdrawn monthly. If no oval is filled above, my credit/debit card will be charged monthly. I authorize ADT to withdraw the amounts in this section from my bank account or credit card through an Automated Clearing House ("ACH"). These payments are for the equipment and services described in this Contract. This authorization will remain in effect until the termination date of this Contract or until I cancel it in writing, whichever occurs first. I also agree to notify ADT in writing of any changes in my account information at least 15 days prior to the next billing date. If a payment date falls on a weekend or holiday, payment may be executed on the next business day. Because this is an electronic transaction, these funds may be withdrawn from my account each month as early as the transaction date. If the date or amount of the withdrawal changes, ADT will notify me at least 10 days prior.to the payment being collected. If an•ACH transaction is rejected for non -sufficient funds (NSF), ADT may attempt to process the charge again within 30 days, and an NSF charge may apply. The origination of ACH transactions to my.account must comply with the provisions of U.S. law. I am an authorized user of this credit card or bank account, and I will not dispute the payment with my credit card company or bank, so long as the amount corresponds to the terms indicated in this Contract. O To send me a bi 11: O Annually Semi -Annually O Quarterly O Other DOA Approval If no oval is filled, ADT will send bill quarterly. Authorized Account Signature. - '/ Section• and System Data 119MEM&16CS I I INameit . Address I State ZIP Cross St. City Premises' Phone #1 / _ Phone #2 O Cell Only Municipality Municipality Police Name Fire Name Municipality Patrol Name Medical Number & Number Job Type ®New Sale O Change Over O Upgrade Control Type O HW (911,11F Permit Affiliation Member # Number Burglar Alarm: Wes O No Fire / Smoke: 0Y--- ettt___s O No Two -Way Voice: O Yes O No Cellular Model: O Parallel O Standard Profile i ? Preferred Monitoring Communication KyY I Account Management Method ' ServicesCodes: Ownership System Service Services Guard j Market Resale -Former L I I I I I I I I IELW/QSP I ! Y Service 11 Group Acct # Former CS # e e • •14 This password must be issued to all users of the alarm system, including all people listed in Section 7- An optional, secondary password for service individuals, housekeepers, tenants, etc. is available upon request. A password must be no less than three (3) and no more than five (5) characters in length and may not contain any punctuation or spaces, offensive language or non-standard spelling. Customer may change passwords and contacts by going to www.MyADT.com or by calling ADT toll -free at 1.800.ADT.ASAP. Contact these are the individuals who may be called in the event of an alarm. Because they+may need to meet the authorities in response to an alarm, I will provide them access to my premises, the password, and the keypad code. By selecting the "Yes" designationon the right I am identifying which of these individuals may be called,prior to notification of the authorities. Customer/Emergency Contact #1 j /E f - 1i ( 1 j J l`r r ] Ho .:. O • O 1PrintFirst/Last Name ff f f L 7 1/ Phone `^'Ir L'"'(±'J,/Home Cell Work Yes NoL I O O O O O Phone- Home Cell Work Yes No i % G O O OCustomer/Emergency Contact #2 '1 (,l j/ _ /` l l <-1 / _ / / %O Print First/Last Name ( 1(f'' Jt C/!" Phone -1 l..I '{,1 ' //v,.Home Cell Work Yes No O O O O O Phone Home.:dell Work Yes No Alternate/Emergency Only Contact O O O O O Print First/Last Name Phone Home Cell Work Yes No O O O O O Phone Home Cell Work Yes No 3of6 2011 ADT. All rights reserved. (04/11) RESIDENTIAL SERVICES CONTRACT III!III III,NI IVIIYVIIIiNlllfII CONTRACT CUSTOMER JOB LEAD DATE MIDI" ACCOUNT NO I 1 '41 1111 1 1 1 NO M SOURCE Monthly Service Charge O Initial/Annual Recurring Municipal Fee billed separately ual Fee s>Standard Monthly Service, Burglary Subject to change based on local law) Service includes: Customer Monitoring Center Signal O Customer to obtain and pay for initial/annual municipal Receiving and Notification Service for Burglary, alarm use permit. Failure to obtain and provide AV with J, tiallAnn Manual Fire and Manual Police Emergency the municipal alarm use permit registration number could result in no municipal fire/police response to an alarm from the premises and/or a fine. O Standard Monthly Service, Fire/Smoke Detection Service includes: Customer Monitoring Center Signal Receiving and Notification Service for Fire, Manual Fire' Municipal Electrical Permit Fee O Customer to obtain electrical permit and Manual Police Emergency O Carbon Monoxide O Flood O Low Temp Installation Price O Medical Alert Taxable Amount A?Safewatch Cellguard® Non -Taxable Amount O SecurityLink® Connection Fee 0 Extended Limited Warranty/Quality Service Plan (QSP) Admin Fee O Guard Response Service Sales Tax on Installation* Q. Other I Deposit Received Total Monthly Service Charge ( Balance Due upon Installation* If applicable sales tax not shown, it will be added to the first invoice. Section• • to be Installed Z i / / a® Control Panel rQ/% a X'oj o'ix o` j \3`° V\a0e ea0e%Cas Oe Sa Q`°a CL P 9r re` P P$ P Qs o Comments Pa _age Name: I Incl Foyer--- Livmg Room I--- I----- r------ - -- -- - -------- -- - - .— Family Room I I Office I T Dining Room i t I Kitchen Laundry Room Hallway I Master Bedroom Master Bath i I i Bedroom 2 E -- -- --- --- - Bedroom 3— Bath 2 I I i i Basement Garage 1.... ......_._ j L r......_...._ Totals D i E = Existing Equipm P stimated Installation Start Date INSTALLER NOTES_ _ ,( / ... ... ... ... i1 / 2 of 6 02011,.ADT. All rights reserved. (04/11)