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HomeMy WebLinkAbout2612 Vineyard CirCITY OF SANFORD BUILDING & FIRE PREVENTION PERMIT APPLICATION Application No: / a Documented Construction Value: $ k6jq-" Job Address: 2-1012-yi►r cyny-d ClrCle Historic District: Yes ❑ No m Parcel ID: 32. 1q -31.521. OOoo• 07-LI0 Zoning: Description of Work: VAo Vol4oA�, aw rI:N Plan Review Contact Person: Phone: Fax: E-mail: Property Owner Information Title: Name D2 1%br-tor\ lrlc.• Phone: Street: 5850 T GLEE 61yc1 5i -C, (POO Resident of property? : Flo City, State Zip: Q&Ando FL 3ZUZ2 Contractor Information Name AuT 5 cur Am &-ry%ces Street: VISO a -1U[ OrA& v City, State Zip: CWICui& R 32t0LO Name: Street: City, St, Zip: Bonding Company: Address: Building Permit O Phone: 4al. o 33S$ Fax: 41. 8210' 35ZO State License No.: E Q300I IV Architect/Engineer Information Phone: Fax: E-m.ail: _ Mortgage Lender: Address: PERMIT INFORMATION Square Footage: ;151A Construction Type: No. of Stories: No. of Dwelling Units: Flood Zone: Electrical e New Service — No. of AMPS: Mechanical 11 (Duct layout required for new systems) Plumbing O New Construction - No. of Fixtures: Fire Sprinkler/Alarm D 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 WITII 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 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: UTILITIES: ENGINEERING: COMMENTS: Rev 11.08 FIRE: I/ / Signa a of Nota state of Florida Date e% NANCY PALMIERI •i MY COMMISSION # EE130451 EXPIRES September 15. 201 5 407)�iB-0163 F NoteryBMMee•ea^ Contractor/Agent is Personally Known to Me or Produced ID Type of ID WASTE WATER: BUILDING: /I POWER OF ATTORNEY Date: 2 211 1 I hereby name and appoint SO_w\_ya I>+cta- of ADT Security Services to drop off and pick up permits at the 3W-)40 t ck • Building Department on my behalf for a LOW VOLTAGE SECURITY permit for wt rk to be performed at a location described as: Parcel 32' 1q•31 •Sz1-Ooao• 0240 Subdivision IU Scano- Pacc_ Sc,,4, - Address ofjob ZU%2 \J;,ncggra e,�r Owner b q- Aon try_ Georgie Manginelli EF0001121 Type or Print Name of Certified Contractor Signahite of Certifil Contractor The foregoing instrument was acknowledged before me this V bj+-c- day of 20 11 by C-WLo , Canaan o U -i who is pe onally k -o t m /who produced as identification and who did not take oath. State of Florida ' County of Orcvic� No Publicl S=ii ei County, Florida C rtr NANCY PALMIERI 'c MY COMMISSION # EE130451 c EXPIRES September 15, 2015 007)�P80157 F1*r1d$N0k0gSWWW.00m A� o® CERTIFICATE OF LIABILITY INSURANCE DA;;/9tiW,/YYYn THIS' CERTIFIt;ATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terns and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: Marsh, Inc. 1166 Avenue of the Americas PHONE FAX /C No : AIC No Erd : 'C. GL 4360884 (Primary GL) New York, NY 10036 ADDRESS: PRODUCER CUSTOMER ID M DAMAGE TO RENTMT- PREMISES Ea occurrence 51 •000•000•00 INSURERS AFFORDING COVERAGE NAIC A INSURED INSURER A: AGCS Marine Insurance Company (Allianz) GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PRO LOC ADT Security Services, Inc. INSURER B: CHARTIS CASUALTY COMPANY E E E F 3160 Southgate Commerce Blvd INSURER C: Commerce & Industry Ins Co. Ste 38 INSURER D: Illinois National Insurance Co. 10/1/2010 10/1/2010 10/1/2010 10/1/2010 Orlando, FL 32806 INSURER E: Nat'l Union Fire Ins Co. of Pittsburgh, PA BODILY INJURY (Per person) United States INSURER F: New Hampshire Ins. Co. NEW HAMPSHIRE (CSL) 5250 DDD COVERAGES CERTIFICATE NUMBER: 827805 - A REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I LTR LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MMOIUDDIYY MOMIVDD EXP LIMITS F GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE D OCCUR OWNER'S d CONTRACTORS GL 4360884 (Primary GL) 10/1/2010 10/1/2011 EACH OCCURRENCE $1,000,000.00 DAMAGE TO RENTMT- PREMISES Ea occurrence 51 •000•000•00 MED EXP (Any one person) $10,000.00 PERSONAL b ADV INJURY $1.000,000.00 GENERAL AGGREGATE $2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PRO LOC PRODUCTS - COMP/OP AGG $2,000,000.00 E E E F AUTOMOBILE X X X LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS CA 3976576 (VA) CA 3976575 (AOS) CA 3976577 (MA) CA 3976624 (NH) (Primary AL) 10/1/2010 10/1/2010 10/1/2010 10/1/2010 10/1/2011 10/1/2011 10/112011 10/1/2011 COMBINED SINGLE LIMIT $1,000,000.00 Each accident BODILY INJURY (Per person) BODILY INJURY (Per accident PROPERTY DAMAGE (Per accident) NEW HAMPSHIRE (CSL) 5250 DDD UMBRELLA UABOCCUR EXCESS LIAR HCLAIMS-MADE EACH OCCURRENCE AGGREGATE DEDUCTIBLE RETENTION $ PRODUCTS - COMP/OP AGG NEW HAMPSHIRE (CSL) B C D E F WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEM(Mandatory In NNR) EXCLUDED? 0 yes describe under DESCRIPTION OF OPERATIONS below NIA A WC 026149514 (FL) WC 026149516 (MI) WC 026149513 (CA) WC 026149518 (MA, NO, NY, OH, I WA. WI WY) 10/1/2010 10/1/2010 10/1/2010 10/1/2010 10N12010 10/1/2011 10/1/2011 10/1/2011 10/1/2011 10/1/2011 I X I WC STATU- DTH - E.L. EACH ACCIDENT 52,000.000.00 E.L.DISEASE • EA EMPLOYE 52.000.000.00 L. DISEASE . POLICY LIMIT 52,000,000.00 A A • I Builder's RisIdinstallation/Contrad Works Rental Equipment/Contraclors Equipment Blanket Transit OC 8 OCW 91128600 OC 8 OCW 91128600 IOC&OCW91128600 5/112010 5/112010 1511/2010 5/1/2011 51112011 15f1r2011 USD $1,000,000.00 per jobsite USD $1,000,000.00 per jobsite USD S11,000.000.00 per conveyanm DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, 11 more space is required) Please refer to attached ACORD 101 for further remarks. CERTIFICATE HOLDER CANCELLATION City of Sanford 300 N Park Ave Sanford, FL 32771 United States SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE MARSH USA INC. BY; F� Mn HOOod . GbbW Malls ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD Generated by EXIGIS LLC. For more information visit www.exigis.com. RESIDENTIALSERVICESCONTRACT IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII 5104UE12 CONTRACT CUSiOMER LEAD DATE ` ACCOUNT NO`S ) 1 - JNO m SOU CE Section• • ADT Security Services, Inc. ("ADT") Customer Name n KNI 1 A III 11111 'I' "me" "my") ' A. NUMBER OF ('Customer" or or or 1�- DIZ Z(1 (� �C.0 AYM NTS OR THE INITIAL TERM IS 36. B. AMOUNT OF EACH PAYMENT IS $ / ', (TOTAL MONTHLY SERVICE CHARGE FROM BELOW) TOTAL OF PAYMENTS FOR THE INITIAL TERM IS (A. TIMES B.) (EXCLUSIVE OF ANY APPLICABLE TAXES, FEES, FINES AND RATE INCREASES) rt PREPAYMENT- IF I PREPAY THE `, SEE SECTIONS 2, 7,15 AND FREQUENCY, PRIOR TO THE START OF'ISERVICE. MY FIRST BILUCHARGE WILL '' TOTAL OF PAYMENTS PRIOR TO 19 OF THIS CONTRACT FOR BE SENT/MADE SHORTLY AFTER MY SERVICE BEGINS. ADT MAY IMPOSE A 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. �iZl � � .D•a� %� 32� I Address (RWMk&U111111City 9 State ZIP Tax Exempt No. Protected Premises' 0:141:1411 Telephone Tax Expire Date O Traditional Phone Other (Qualified) O Other (Non -Qualified) www.MyADT.com 1.800.ADT.ASAP• Alternate 1 q441 8 (1.800.238.2727) Telephone 1 4Home O Cell O Work Alternate .. IF FAMILIARIZATION PERIOD 15 REJECTED INITIAL -HERE Telephone 2 O Home O Cell O work I (see Paragraph 14 of the Terms and Conditions for explanation) EMAIL ( I 7 (`bl n ' `� J (L p C TM 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 donotcontad®ADT.com or by calling 888.DNC4ADT (888.362.4238). Initial here ; Cohfirmation 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 ®'ADT -Owned I ACKNOWLEDGE AND AGREE TO EACH OF THE FOLLOWING: (A) THIS CONTRACT CONSISTS OF SIX (6) PAGES:.BEFUREj!AG WG THIS.CONTRACR+I HAVE READ, UNDERSTAND AND AGREE TO EACH AND EVERY TERM OF THIS CONTRACT, INCLUDING BUT NOT LIMITED TO PARAGRAPFIS'S )IND 46� -- THE TERMS AND CONDITIONS. (B) THE INITIAL TERM OF THIS CONTRACT IS THREE (3) YEARS. (C) ADT IS NOTA SECURITY CONSULTANT AND.CANNOT ADDRESS ALL OF -MY POTENTIAL -SECURITY NEEDS. ADT HAS EXPLAINED T6 ME THE FULL RANGE OF EQUIPMENT AND SERVICES THAT A'DT 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 15 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.MY DT.0 IM. (F) THIS CONTRACT REQUIRES FINAL APPROVAL BY AN ADT AUTHORIZED MANAGER BEFORE ADT MAY PROVIDE ANY EQUIPMENT OR SERVIC S, AND IF APPROVAL 8 DENIED;•THEN THIS CONTRACT WILL BE TERMINATED, AND ADT'S ONLY OBLIGATION WILL BE TO NOTIFY ME OF SUCH TER I ON AND REFUN 'ANY AMOUNTS I AID IN DVA CE. ADT Rp s t e Na e Rep. License No. Rep. (If Required) ID No. Customer's Approval: Origin Signature Required ( ust match Customer Name in Section 1 above) X 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 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. 1.. . Section• be Provided FINANCIAL DISCLOSURE STATEMENT THERE IS NO FINANCE CHARGE OR COST OF CREDIT (0% APR) ASSOCIATED WITH THIS CONTRACT. A. NUMBER OF $ / /4? AYM NTS OR THE INITIAL TERM IS 36. B. AMOUNT OF EACH PAYMENT IS $ / ', (TOTAL MONTHLY SERVICE CHARGE FROM BELOW) TOTAL OF PAYMENTS FOR THE INITIAL TERM IS (A. TIMES B.) (EXCLUSIVE OF ANY APPLICABLE TAXES, FEES, FINES AND RATE INCREASES) LATE CHARGE - PAYMENT IS DUE PURSUANT TO MY SELECTED BILLING PREPAYMENT- IF I PREPAY THE `, SEE SECTIONS 2, 7,15 AND FREQUENCY, PRIOR TO THE START OF'ISERVICE. MY FIRST BILUCHARGE WILL '' TOTAL OF PAYMENTS PRIOR TO 19 OF THIS CONTRACT FOR BE SENT/MADE SHORTLY AFTER MY SERVICE BEGINS. ADT MAY IMPOSE A 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 SERVIrES CONTRACT iumn104Uuna�ii CONTRACT LEAD DA E CUSTOMER�/m ACCOUN NO NO m SOURCE CONTRACT Section 2. Services to be Provided (continued) Monthly Service Charge O Initial/Annual Recurring Municipal Fee billed separately Initial/Annual Fee 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, Manual Fire and Manual Police Emergency alarm 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 Municipal Electrical Permit Fee D -T Receiving and Notification Service for Fire, Manual Fire O Customer to obtain electrical permit and Manual Police Emergency Installation Price $ 311J O Carbon Monoxide O Flood O Low Temp O Medical Alert $ Taxable Amount qgSafewatch.Cellguard° $ �' V IC Non -Taxable Amount O SecurityLink• Connection Fee *Extended Limited Warranty/Quality Service Plan (QSP) $ / ,y --✓l`'' Admin Fee $ O Guard Response Service Sales Tax on Installation* O Other V �S� _ `-- L 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 Nt Control t \� / ��\� SeoS° e�eZ`° at s ,� 5 °o°s �c,,°' �¢�a �r Loop¢ `ar�. e�,cA PanelSF°°� °` C.a a``�• pe�ay�•Oa Qo�ro°, Qo�`'Q°�Si r pO�P�pO �o°� po°i/yS`�j°�\ V�aOe�,ZeaJpe�a �,� p0 POS r¢ j� Qi`� Comments g N ( ' R � j r� , • 3277 include /- v� Foyer I •, Living Room Y Family Room I Office a Dining Room Kitchen Laundry Room Hallway Master Bedroom ~� l/ Master Bath Bedroom 2 --- Bedroom 3 L_ Bath t Basement I �� --- ---- --I r— — — -- - Garage TOtd15 I E = Existing Equipment Estimated Installation Start Date LLJ� t" LJ� L1J INSTALLER NOTES PI q\6g LiR —�- �Jh��J _ IJ�� JT C ! &-(� �-/ �fl�S �� C__r'i T --- - -�� UfEfy - -- Jam- ��N (t -J / - .77 77 --- 2 Of 6 .02011 ADT. All rights reserved. (04/11) RESIDENTIAL SERVICES CONTRACT ( Gm.) iuA�winiwuni� CONTRA T 1117� CUSTOMERE � ACCOUNT O % ' ,NO M SOURCE SectionBilling O Check received for: O Installation: Check # Amount O Annual Service Charges Collected: Check # Amount $11111 J 11 1 I authorize ADt- Cao withdraw all Service Charges from my bank account: 40 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 Sa,,'^-, (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 15 All/Recurring Service Charges O Annually O Semi-AnnuallAO Quarterly 10Monthly F_�R ABA Routing'Number Bank Account Number 19 VISA O MasterCard O Discover O AMEX Credit/Debit Card Number Ex iration Date Recurring Service Charge Amount $1 11 11 J TI MMMM1=q(qq7 Wo M M Y Y Name as it appears on bank account Recurring Service Charge Amount C d older's Name I authorize ADT to debit my bank account for the amount of all Recurring Service Charges If I am usin 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 credit1debit 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 O Semi -Annually O Quarterly O Other DOA Approval If no oval is filled, ADT will send bill quarterly. Authorized Account 5ignature00%::�'��- Section 5. Customerand System Data Name CS # ` I 1114ON-1W WAWA I I I I I I I 1 1 FM I I I I I I I I I I 1� Address ..r .11 ' ' City State ..r ZIP Cross St. > Premises' Phone #1 Phone #2 O Cell Only Municipality Municipality Police Name Fire Name Municipality Patrol Name Medical Number &Number Job Type lNew Sale O Change Over O Upgrade Control Type O HW ® RF Permit Affiliation Member # Number Burglar Alarm: ® Yes O No Fire l Smoke: O Yes 8 No Two -Way Voice: eYes O No Cellular Model: O Parallel 15 Standard Profile© © Preferred Monitoring ® Communication Account Management Iq Codes: Ownership System Service Services Metho •�I Services Guard MarketResale-Former To 1 1 ITTMFormir ELW/QSP Service Group Acct #.`. CS # Section• Password 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. Section•eContact 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" designatio% on the right I m identifying.which of these individuals may be called prior to notification of the authorities. Customer/Emergency Contact #1 • •O ® O • O ���� 17R�^I� �Q Print FirsVlast Name lJyy Phone / rV Home Cell Work Yes No O O O 0,;. O. Phone Home Cell Work Yes �p Customer/Emergency Contact q2 PrZ Z g O 9 O O ' Home Cell rk Yes No Print First/Last Name Phone �/ � /r O O'er � 69 C) o Phone Home Cell Work Yes No Alternate/Emergency Only Contact O O O O O Print First/Last Name 1 Phone Home Cell Work Yes" No, O O O O O ' Phone Home Cell Work Yes No 1 1-� 3 Of 6 02011 ADT. All rights reserved. (04/11)