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HomeMy WebLinkAbout10204 Fox Quarry Lnrtio�TITIT r_> AUGI CITY OF SANFORD BUILDING & FIRE PREVENTION PERMIT APPLICATION Application No: ( I J0 a I Documented Construction Value: $9 • Cep Job Address: _10a04 O L c 37'11storic District: Yes ❑ No ❑ Parcel ID: %a -aQ - 30 -31C,0 - O\a-c - 0000 Zoning: Description of Work: 1Vo Plan Review Contact Person: Phone: Fax: Title: E-mail: Property Owner Information Name C,inuc\es-Iv(\ Cl.n \tiA. Cyis LT Street: 15 51 SG aca City, State Zip: MC;. ctc\A F L 3 al Phone: Resident of property? : nn Contractor Information Name Phone: 4ol-% a 6 - 3a33 Street: A-PI1 Fax: City, State Zip: �t �[�,n o , rrL Aat 1 _,�L State License No.: t F 000 11 d 1 Name: Street: City, St, Zip: Bonding Company: Address: Building Permit ❑ Square Footage: 10 No. of Dwelling Units: Electrical av New Service - No. of AMPS: Architect/Engineer Information Phone: Fax: E-mail: Mortgage Lender: Address: PERMIT INFORMATION Construction Type: Flood Zone: Mechanical ❑ (Duct layout required for new systems) Plumbing ❑ No. of Stories: New Construction - No. of Fixtures: Fire Sprinkler/Alarm 0 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. 1 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 orOwner/Agent Date Print 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: ENGINEERING: COMMENTS: Rev 11.08 UTILITIES: FIRE: 16// Signature of Corincto/r� ,gent Date Print Contract /o�r/A eA 1. Name Q� Signature of Notary -State of Florida Date ;v ASHLEY AMMONS ;:�... MY CAMMISSION H DO 893481 `� EXPIRES: May 27, 2013 ar' Bonded Thn] Notary Public Underwriters Contractor/Agent i ersonally Known to Me or Produced ID Type of ID WASTE WATER: BUILDING: POWER OF ATTORNEY Date: I I ;19 / ao lk o T hereby name and appoint D11\ C Ctif1 of ADT Security Services to drop off and pick up permits at the 4 .ryi;CO CCL • Building Department on my behalf for a LOW VOLTAGE SECITRI'I Y permit for work to be performed at a location described as: Parcel �a, _ a\ o - 3o - 30�o - o tax - o000 Subdivision 61h�n Address of job Owner (hG.i�e5 n �1u� ?CwC-It eCG L.T O Georgie ManOneIIi EF0001121 Type or Print Name of Certified Contractor Signawc ofCr . ntraotor The fora4zoing instrument was acknowledged before me this / day of 20-4 Y who is personally known tS me/who produced _ as identification and who did not take oath. State of Florida County of Notary Public, eminole County, Florida AMMONS MY COMMISSION U 0 893481 ';:c EXPIRES: May 27, 2013 ' Rf Bonded Thru Notary Pubic Undery ricers 3 Seminole County Property Appraiser Get Information by Parcel Number Page 1 of 2 Personal Property I Please Select Account http://www.scpafl.org/web/re_web.seminole_county_title?parcel=122030300012X0000&c... 7/29/2011 DAVID JOHmsom. CFA, ASA PROPERTY APPRAISER SE34INOLE COUPnY FI-. <ZY ... C w'• r1 � �,•` � ;. •, t` "��.ss\` 3 11 Ot E. FIrsT sT sANromD. VL3277/•146e 407.665-7506 1,., c _ ' M t., i VALUE SUMMARY VALUES 2011 2010 Workinst Certified GENERAL Value Method Income Income Number of Buildings 14 14 Parcel Id: 12-20-30-300-012X-0000 Depreciated Bldg Value $0 $0 Owner: CHARLESTON CLUB PARTNERS LTD Depreciated EXFT Value $0 $0 Mailing Address: 1551 SANDSPUR RD Land Value (Market) s0 $0 CIty,State,ZlpCode: MAITLAND FL 32751 Land Value Ag $0 $0 Property Address: 500 FOX QUARRY LN SANFORD 32773 ,�VjtV�r�@t V $8,773,389' $8,046,214 Facility Name: CHARLESTON CLUB Portablity, AdJ $0 $0 Tax District: S1-SANFORD Exemptions: Save Our Homes Ad) $0 $0 Dor: 03 -MULTI FAMILY 10 OR M Amendment 1 Ad) $0 $0 Assessed Value (SOH) $8.773,389 ' $8.046.214 Tax Estimator (' Income Approach used.) 2011 TAXABLE VALUE WORKING ESTIMATE Taxing Authority Assessment Value Exempt Values Taxable Value County General Fund $8,773,389 $0 $8,773.389 (Amendment 1 adjustment is not applicable to school assessment) Schools $8.773,389 $0 $8,773,389 City Sanford $8.773,389 $0 $8,773,389 SJWM(Saint Johns Water Management) $8.773,389 $0 $8,773,389 County Bonds $8.773,389 $0 $8.773,389 The taxable values and taxes are calculated using the current years working values and the prior years approved millage rates. SALES 2010 VALUE SUMMARY Deed Date Book Page Amount Vaclimp Qualified 2010 Tax Bill Amount: $161,624 WARRANTY DEED 05/2001 04074 1757'$2,250,000 Vacant Yes 2Q10 Certified Taxable Value and Tax@g DOES NOT INCLUDE NON -AD VALOREM ASSESSMENTS Find Sales within this DOR Code LEGAL DESCRIPTION SEC 12 TWP 20S RGE 30E BEG 287.24 FT S OF NE COR OF SW 1/4 RUN S 984 85 FT W ALONG RNV 75 FT N 280.60 FT W 280 FT S 282.95 FT WLY ALONG RNV 243.67 FT WLY & SWLY ALONG CURVE 399.05 FT N 31 DEG 09 MIN 27 SEC W 378.70 FT NWLY ALONG CURVE 210.63 FT S 84 DEG 57 MIN 54 SEC E 6.42 FT N 80 DEG 18 MIN 30 SEC E 5203 FT N 82 DEG 14 MIN 13 SEC E 84.60 FT N 68 DEG 49 LAND MIN 17 SEC E 41 43 FT N 81 DEG 02 MIN 07 SEC E 57.67 FT N 70 DEG 01 MIN 05 SEC E 71.43 FT N 80 DEG 40 MIN 38 Land Assess Method Frontage Depth Land Units Unit Price Land Value LOT 0 0 288.000 5,000.00 $1,440,000 SEC E 41.78 FT N 66 DEG 42 MIN 49 SEC E 57.46 FT E 39.34 FT N 69 DEG 46 MIN 42 SEC E 102.66 FT N 87 DEG 08 MIN 54 SEC E 74.29 FT N 66 DEG 58 MIN 27 SEC E 68.18 FT N 48 DEG 17 MIN 07 SEC E 83.03 FT N 31 DEG 49 MIN 58 SEC E 47.88 FT N 31 DEG 36 MIN 55 SEC E 68.85 FT N 38 DEG 52 MIN 13 SEC E 59.32 FT N 77 DEG 25 MIN 49 SEC E 50.45 FT N 88 DEG 17 MIN 12 SEC E 49.60 FT N 25 DEG 16 MIN 13 SEC E 41.14 FT N 45 DEG 58 MIN 26 SEC E 88.46 FT N 47 DEG 11 MIN 58 SEC E 49.98 FT E 49.12 FT N 82 DEG 12 MIN 05 SEC 48.09 FT N 85 DEG 10 MIN 15 SEC E 67.13 FT N 09 DEG 22 MIN 59 SEC E 17.83 FT E 57.78 FT TO BEG (LESS RD) BUILDING INFORMATION http://www.scpafl.org/web/re_web.seminole_county_title?parcel=122030300012X0000&c... 7/29/2011 Seminole County Property Appraiser Get Information by Parcel Number Bld Num Bid Class Year Bit Fixtures Gross SF Stories 1 MULTIFAMILY 2002 156 23,788 3 Subsection / Sgft OPEN PORCH FINISHED 13464 2 MULTIFAMILY 2002 180 25,752 3 Subsection / Sqft OPEN PORCH FINISHED 13400 3 MULTIFAMILY 2002 180 25,752 3 Subsection / Sgft OPEN PORCH FINISHED 13400 4 MULTIFAMILY 2002 204 27,880 3 Subsection I Sqft OPEN PORCH FINISHED 13400 5 MULTIFAMILY 2002 204 27,880 3 Subsection I Sqft OPEN PORCH FINISHED 13400 6 MULTIFAMILY 2002 180 25,752 3 Subsection / Sgft OPEN PORCH FINISHED 13400 7 MULTIFAMILY 2002 204 27,880 3 Subsection / Sgft OPEN PORCH FINISHED 13400 8 MULTIFAMILY 2002 180 25,752 3 Subsection I Sqft OPEN PORCH FINISHED 13464 9 MULTIFAMILY 2002 204 27,880 3 Subsection I Sqft OPEN PORCH FINISHED 13400 10 MULTIFAMILY 2002 204 27,880 3 Subsection I Sqft OPEN PORCH FINISHED 13400 11 MULTIFAMILY 2002 204 27,880 3 Subsection I Sqft OPEN PORCH FINISHED/ 3400 12 MULTIFAMILY 2002 180 25,752 3 Subsection I Sqft OPEN PORCH FINISHED 13464 13 MASONRY PILAS 2002 17 3,260 1 Subsection I Sqft OPEN PORCH FINISHED 1234 Subsection I Sqft OPEN PORCH FINISHED 13115 Subsection I Sqft OPEN PORCH FINISHED/ 477 14 MASONRY PILAS 2002 0 855 1 Permits 998 Page 2 of 2 Ext Wall Bid Value Est. Cost New STUCCO WITH WOOD OR METAL STUDS $1,348,325 $1,400,857 STUCCO WITH WOOD OR METAL STUDS $1,474,896 $1,532,359 STUCCO WITH WOOD OR METAL STUDS $1,474,896 $1,532,359 STUCCO WITH WOOD OR METAL STUDS $1,584,856 $1,646,604 STUCCO WITH WOOD OR METAL STUDS $1,584,856 $1,646,604 STUCCO WITH WOOD OR METAL STUDS $1,474,896 $1,532,359 STUCCO WITH WOOD OR METAL STUDS $1,584,856 $1,646,604 STUCCO WITH WOOD OR METAL STUDS $1.475,988 $1,533.494 STUCCO WITH WOOD OR METAL STUDS $1,584.856 $1,646,604 STUCCO WITH WOOD OR METAL STUDS $1,584,856 $1,646,604 STUCCO WITH WOOD OR METAL STUDS $1,584,856 $1,646,604 STUCCO WITH WOOD OR METAL STUDS $1,475,988 $1,533,494 VINYL WITH WOOD OR METAL STUDS $251,014 $282,833 STUCCO WITH WOOD OR METAL STUDS $35,110 $39,561 EXTRA FEATURE Description Year Bit Units EXFT Value Est. Cost New POOL GUNITE 2002 1.470 $29,621 $38,220 CONCRETE PATIO 2002 2,630 $5,096 $6,575 WOOD DECK 2002 500 $2,880 $4,500 GAZEEBO 2002 169 $1,622 $2,535 ALUM FENCE 2002 377 $877 $1,131 VINYL FENCE/COMM 2002 66 $277 $396 WALKS CONC COMM 2002 5,340 $13.698 $17,675 COMMERCIAL ASPHALT DR 2 IN 2002 211,550 $149.196 $192,511 4' CHAIN LINK FENCE 2002 742 $2,078 $2,968 SEAWALL 2002 4.196 $71,382 $83,920 6' CHAIN LINK FENCE 2002 998 $4,193 $5,988 VINYL FENCE/COMM 2002 1,110 $4,664 $6,660 MAIL KIOSK 2002 31 $374 $584 POLE LIGHT STEEL 1 ARM 2002 7 $6,748 $6,748 POLE LIGHT STEEL 2 ARM 2002 1 $2,520 $2,520 POLE LIGHT CONCRETE 2 ARM 2002 27 $70,038 $70,038 IRON GATE 2002 60 $233 $300 GATE OPENER 2002 4 $3,100 $4,000 BRICK WALL 2002 544 32,530 $3,264 BRICK WALL 2002 426 $1,981 $2,556 LOAD WELL 2002 840 $977 $1,260 ALUM CARPORT NO FLOOR 2002 21,131 $59,192 $84,524 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 Durchased a homesteaded DroDerty vour next vest's Drooerty tax will be based on Just/Market value. http://www.scpafl.org/web/re_web.seminole_county_title?parcel=122030300012X0000&c... 7/29/2011 RESIDENTIAL SERVICES CONTRACT(IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII 5104UE12 CONTRACT DA E® G ACCO NT N� J D JOB m LEAD C NO SOURCE Section• • ADT Security Services, Inc. ("ADT") Customer Name G D 1* 111 ITI I Office Address ('Customer" or "I' or "me" or "my") /, $ �� 697 PAYMENTS FOR THE t B. AMOUNT OF EACH PAYMENT IS TOTAL OF PAYMENTS FOR THE INITIAL TERM IS INITIAL TERM IS 36. (TOTAL MONTHLY SERVICE CHARGE FROM BELOW) AND RATE INCREASES) LATE CHARGE - PAYMENT IS DUE PURSUANT TO MY SELECTED BILLING PREPAYMENT ENT - IF I PREPAY THE SES E SE S SECTIONS 2, 7, 15 AND FREQUENCY, PRIOR TO THE START OF SERVICE. MY FIRST BILL/CHARGE WILL TOTAL PAYMENTS PRIOR TO THIS CONTRACT FOR BE SENT/MADE SHORTLY AFTER MY SERVICE BEGINS. ADT MAY IMPOSE A TIAL TER M THE END OF THE INITIALR ADDITIONAL INFORMATION ONE-TIME LATE CHARGE ON EACH PAYMENT THAT IS MORE THAN TEN (10) THIS CONTRALTITHERE NO ABOUT NONPAYMENT, DEFAULT DAYS PAST DUE, UP TO THE MAXIMUM AMOUNT PERMITTED BY LAW, BUT IN PENALTY OR REFUND. AND ACCELERATION. NO EVENT WILL THIS AMOUNT EXCEED $5.00. 1101,010 14VX1 Z v 144W,61 11 11 11 111111 Address 11111111111111 11 City S F ` State ZIP Tax Exempt No. Protected Premises' Telephone Tax Expire Date O Traditional Phone O Other (Qualified) O Other (Non -Qualified) www.MyADT.com 1.800.ADT.ASAP• Alternate / 7 / (1.800.238.2727) Telephone 1 O Home O Cell O Work Alternate IF FAMILIARIZATION PERIOD IS REJECTED INITIAL HERE Telephone 2 O Home O Cell O Work (see Paragraph 14 of the Terms and Conditions for explanation) EMAIL Communications Authorization: I authorize ADT to provide me with information and updates about the security system and new ADT and third -party products and services to the contact information 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 calling 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 b 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) ADT IS 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 F,QUIPMENT 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.AD.T.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. Customers Approval: Ori inal S' atureRequired (Must match Customer Name in Section 1 above) X D7 Z l l V I NOTICE OF CANCELLATION 1, 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 OF CANCELLATION 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. Section• be Provided FkkNCIAL DISCLOSURE'STATEMENT - THERE IS NO FINANCE CHARGE OR COST OF CREDIT (0% APR) ASSOCIATED WITH THIS CONTRACT. A. NUMBER OF �!� /, $ �� 697 PAYMENTS FOR THE t B. AMOUNT OF EACH PAYMENT IS TOTAL OF PAYMENTS FOR THE INITIAL TERM IS INITIAL TERM IS 36. (TOTAL MONTHLY SERVICE CHARGE FROM BELOW) AND RATE INCREASES) LATE CHARGE - PAYMENT IS DUE PURSUANT TO MY SELECTED BILLING PREPAYMENT ENT - IF I PREPAY THE SES E SE S SECTIONS 2, 7, 15 AND FREQUENCY, PRIOR TO THE START OF SERVICE. MY FIRST BILL/CHARGE WILL TOTAL PAYMENTS PRIOR TO THIS CONTRACT FOR BE SENT/MADE SHORTLY AFTER MY SERVICE BEGINS. ADT MAY IMPOSE A TIAL TER M THE END OF THE INITIALR ADDITIONAL INFORMATION ONE-TIME LATE CHARGE ON EACH PAYMENT THAT IS MORE THAN TEN (10) THIS CONTRALTITHERE NO ABOUT NONPAYMENT, DEFAULT DAYS PAST DUE, UP TO THE MAXIMUM AMOUNT PERMITTED BY LAW, BUT IN PENALTY OR REFUND. AND ACCELERATION. NO EVENT WILL THIS AMOUNT EXCEED $5.00. 1 of S' Administrative Conv 4-0n11 nrnT All .;-k+. .e.e.. 4 1AA111% 0 RESIDENTIAL SERVICES CONTRACT iuniiruidn CONTRACT LEAD DA E Z, ACCO NSTO M NO m SOU CE Section 2. Services to be Provided (continued) 1E) Standard Monthly Service, Burglary Service includes: Customer Monitoring Center Signal Receiving and Notification Service for Burglary, Manual Fire and Manual Police Emergency Monthly Service Charge O Initial/Annual Recurring Municipal Fee billed separately (Subject to change based on local law) Initial/Annual Fee !alarm 7 O Customer to obtain and pay for initial/annual municipal use permit. Failure to obtain and provide ADT with 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 and Manual Police Emergency Municipal Electrical Permit Fee O Customer to obtain electrical permit �7 (� / 7 O Carbon Monoxide O Flood O Low Temp $ ___j Installation Price $ O Medical Alert $ Taxable Amount $ 0 Safewatch Cellguard• $� Non -Taxable Amount $ O SecurityLink' $ Connection Fee $ © Extended Limited Warranty/Quality Service Plan (QSP) I / $ IN L Admin Fee $ O Guard Response Service $ Sales Tax on Installation* $ 7%�6 OOther $ Deposit Received $ 3p Total Monthly Service Charge $ ��. dl/ Balance Due upon Installation* $ *If applicable sales tax not shown, it will be added to the first invoice. Section• • to be Installed Contro e—) a�1 50101C, V- � S S o�,oS�aerL¢��°'°a �e�a 0 Panel J�Qa `Seo `0x08 000a�S¢`eaJS¢a�0¢e�aye�ae�. �L o�Qo:��O�Qo¢�o�QoQ��a� Comments Packageame: Includes: Foyer Living Room Family Room Office Dining Room Kitchen Laundry Room Hallway Master Bedroom ` -Master Bath Bedroom 2 Bedroom 3 Bath 2 Basement' - , •• - Garage Totals I 1 I I I E= xisting Equipment Estimated Installation Sta "Date INSTALLER NOTES 2 of 6 02011 ADT. All rights reserved. (04/11) RESIDENTIAL SERVICES CONTRACT I�I51IMN2IIIN CONTRACTDATE Z ULJ ACCOUNT NOM7JOB LEAD NO SOURCE Section 4. Billing 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: 0 To charge my credit/debit card for: O Annually O Semi -Annually O Quarterly O Monthly O 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 • P All/Recurring Service Charges O Annually O Semi -Annually O Quarterly ©Monthly ABA Routing Number Bank Account Number a VISA O MasterCard O Discover O AMEX Credit/Debit Card Number Expiration Date j L• 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 bil I: O Annually O Se i -Annually O Q arterly O Ot DOA Approval If no oval is filled, ADT will send bill quarterly. 1' Authorized Account Signature Z, ' Section• and System Data L / t, 1 &14*11 FFFTT Name CS #W 0 D 17) x 1 �'y U A ,2 Rl Address ` / P If G' � fl 1 1 1 1 1 1 1 1 1 J �� City State ZIP � ��J Cross St. R_ / '111 A* / Premises' Phone #1 N j Phone #2 11 1 1 1 IT 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 -0 RF Permit Affiliation Member # Number Burglar Alarm: © Yes O No, Fire / Smoke: O Yes b No Two -Way Voice: O Yes -0 No Cellular Model: O Parallel O Standard 1 Profile -Preferred Monitoring Communication t Account Management� GJ ® Codes: Ownership System Service Service E Method ServicesEE % � GuardMarket Resale -Former ® ® ELW/QSP Service Group Acct # Former CS # Section• Password This password.must be issued to all users of the alarm system: includTg•all people lilted in.,Section7. An�optignal, 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)icharacters 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. Section•'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" designation on the right I am identifying which of these individuals may be called prior to notification of the authorities. Customer/EmergencyContact #1 K O 0' O • O LiaT19Ym �' h �G' Print First/Last Nam9S /07aia Phone u Home Cell Work Yes No O O O 00 Phone Home Cell Work Yes No Customer/Emergency Contact #2 /' / / —7 l O © O O Q �1f 107• �� I Print First/Last Name �F /f Phone / / Home Cell Work Yes No O O O 00 Phone Home Cell Work Yes No Alternate/Emergency Only Contact l�„ / ! — r - O 10 O O 'a L-+�'� �C)�� �J Print First/Last Name r'L� ���� L��% Phone Home Cell Work Yes No O O O 00 Phone Home Cell Work Yes No •3 Of 6 02011 ADT. All rights reserved. (04/11)