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EL-11-1922Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 167282 Permit Number: EL -10 -11 -1922 Scheduled Inspection Date: December 05, 2011 Inspector: Devaney, Michael Owner: ALCONERO, RAUL Job Address: 9818 NW 1 Avenue Miami Shores, FL 33150- Project: <NONE> Contractor: ADT SECURITY SERVICES, INC Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Alarm Phone Number Parcel Number 1131010240070 Phone: (786)331 -3967 Building Department Comments burglar alarm installation Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments December 02, 2011 For Inspections please call: (305)762 -4949 Page 31 of 46 69? /609i Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 Permit No. 1 l i 22 Master Permit No. BUILDING PERMIT APPLICATION FBC 20 Permit Type: Electrical OWNER: Name (Fee Simple Titleholder): etc) -/low % re phone#: ! (/ -63 46! Address: % WY ,�� !U�'a State City: /I'1 / C gip: 3 31 51) Tenant/Lessee•Name: Phone #: Email: CCT 1. 2011 JOB ADDRESS: OF /4? me // ! ��C .. City: Miami Shores �C7ounty: Miami Dade Folio/Parcel#: ii" d/ �� V` O ! 0 Is the Building Historically Designated: Yes NO Flood Zone: Zip: CJ' ✓ CONTRACTOR: Company Name: Address: / ' a //.1 City:'? Qualifier Name: State Certificatio or Re istation #: Contact Phone#: DESIGNER: Architect/Engineer: Phone#: State: Phone#: Email Address: Certificate of Compe Q Zip: g3/579 ��y Phone#: ! g 0 ^ � 5Z' ncy #: rd../ hi ,1 j 1;a7 -#(- -' Value of Work for this Permit / ! ' Square/Linear Footage of Work: Type of Work: ❑Address itlAlteration UNew CI Repair/Replace ❑Demolition Description of Work: >(.0 vl lir�w \ J1 ******** * * * * * * * * * * * * * * * * * * * * * ** * * * * * * ** Fees * * * * * * * ****** any*** * *M********** ******** ***** Submittal Fee $ Permit Fee $ 7 `' e-' ' d'" CCF $ CO /CC $ Scanning Fee $ 'Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ . Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip 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 the 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 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. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature ... - ,1 Signature Owner or Agent Contractor / The foregoing instrument was acknowledged before me this 3 {The foregoing instrument was acknowledged before me this/ /� day of d GT , 20 f f , by /7Q ' e i_ N o'4 C'2e `da fof'i�(� , 20'7 , by who is personally known to me or who has produced Z-P who is personally known to me or who has produced tf As identification and who did take an oath. as identification and who did take an oath. NOTARY PUBLIC: ' G 6 Z6 d 7 Z,S — 66 - 7eCt -6 NOTARY PUBLIC: o® x-66 Sign: Print My Commission Expires: A04 607 sp****= kNa*********** Dk. ;: :..>.**** aksH*sHHa*agsksla*akskHasRHask= k*akHaxaHSHas Ia***sHskshsksx*skskda****Ifa6k.....,` ak33a�ksR a 'xd 'slsala,,,...1_: -, s,. > -- ; 0*0*0 Plans Examiner Zoning Sign: Print: - _ ALBA H. AGUILA My Co iiriq ary Public - State of Florida �,f My Comm. Expires Jul 26, 2015 Commission # EE 106656 APPROVED Structural Review (Revised 07 /10 /07)(Revised 06 /10i2009)(Revised 3/15/09) Clerk .4 ,7'f'. P. Type of Lain A. Settlement Statement (HUD -1) 1.0 FHA 2.0 FINS 3.k Corv. !JNne, l 8. FIte Numb 4.0 VA 5.0 Cony. Ins. II 11.1373 C. Note: This farm is furnished to give you a statement of actual settlement costs. Amounts paid M and by the settlement a are shown. Items • me*ked "(p.o.,;.%)" yore paid oufeidea the closing; ;hey are shover here for Informative Dump = 741 :� OM Approval No. 2602 -02135 7. Loan Ntrnbbe, A. Mortgage Insurance Case Number • ..wu r.. v, aauno Poole E. Gregoire 6818 NW 1 Ave Miami Shores, FL 33150 G. Property Location 9818 NW 1 Ave. NIleml Shores, FL 33150 Itondeur Capital Corporatlor ONE CITY BOULEVARD WEST ORANGE , CA 92868 4. SUMMARY OF BORROWERS TRANSACTION; _100. GROSS AMOUNT DUE FROM ®ORROWER 101. Contract safes prices. 102. Personal property �- 103.. ettlem =nt Ohs to borrower Tine 1400) 104 105, 107 108:: 109,; 110. H. Settlement Agent Ad Valororn Title LLC 954.607.5324 PIaCe Of Settlement 1801 North Plne Island ate. 103 Plantation, Florida 33322 L Settlement hate 08/03111 K. SUMMARY OF SELLERS TRANSACTION; 400. GROSS AMOUNT DUE TO SELLER 139,000,00 401. Conyttet sales prfEg 402. Personal property 139,000.00 1,880.50 403. 404. 405. 'ustmen for items seller in advance AdJuotments for Items peid by seller in advance flown taxes to 406. C.y /town taxes to un tax : to to 112. 407. County taxes to 408, Assessmuts to 405. 120. t$ROSS AMOUNT DUE FROM BORROW.ER 149,880.50 200. AMOUNTS PAID HY OR IN BEHALF OF 15QRROWER 201. wit or earnest money 202. Principal amount of new loer(e) 203. Existing leans) taken sub -- ... to 204. 205. 206. Credit for Termite Treatment 207. 208. 2.000.00 410. 411. 412. 209. stmente for items u 420. GROSS AMOUNT DUE TCISELLER 500. REDUCTIONS IN AMOUNT TO SELLER 601. EXCJess Deposit (see Instructions) 502. Settlement charges to seller (line 1400) 503. Existing loans taken subject to 504. Payoff of first mortgage loan ,139,000.00 10,714.00 505. P •fl of second mod -age loan 820,00 508. Credit for Termites Treatment 820.00 2 933.31 214. 215. 216. 217. 218. 219 4 493,41 220, TOTAL PAID BY i' FOR BORROWER 300. CASH AT SETTLEMENT FROM OR TO BORROWER 301. Grose amount due frorn borrower 120 302. Less amounts paid byffor borrower (J e 220 303. CASH FROM BORROWER 08-03-2011 at 3:08 PM 519, Code Enforcement a_dmfn fee 42000.00742 519. 5 783.31 520, TOTAL REDUCTION AMOUNT DUE SELLER 800. CASH AT SETTLEMENT TO OR FROM 140 880.53 601. Gross emoun due to seller tine 420 5 753.31 602. Less reductior amount due to seller fine 320 135 127.19 603, CASH Page 1 of 3 TO SELLER 8 634.1: 139 000.05 35,634.18 103 365.82 HUD -1 4. Roeio E. Gregoire 9818NWjAve Miami Shores, FL 33150 1 G. Property Location 9818 NW 1 Ave. Miami Shores, FL 33150 Kondaur Capital Corporation ONE CITY BOULEVARD WEST I ORANGE . CA 92868 J. $UNIMARY OF BORROWER'S TRANSACTION: 100, GRO88 AMOUNT DUE FROM BORROWER 101, Contract sates ,rice 102. *ersonal . o•e 103. Settlement cha to borrower (line 1400 104. 10b. d Uetmente for items • aid setter in advance 105. Clty/town taxes to 1071�Runty taxes to 10:4sessments H, Settlement Agent Ad Valorem Title LLC 984.807.5324 Place of Settlement 1801 North Pine Island ate.103 Plantation, Florida 33322 I, Settlement Date 08/03/11 139 000.00 K. SUMMARY OF SELLER'S TRANSACTION: 400 GROSS AMOUNT DUE TO SELLER 401. Co treot sales • ri n, 402. Personal property 880.50 403. 405. Ad u9tments for items 408. C ;town taxes 407. Coun taxes 08, Assessor is 409. d by seller In advance 139 000.00 120.6ROSS AMOUNT DUE FROM SORROW R 203. AMOUNTS PAID EY OR IN BEHALF OF tORROWER 201, Deposit or tamest money 202. Principal amount of new loan 140 880.50 203. Existing loan's; taken sub to 204, 42 *• CAROBS AMOUNT DUE 1. SELLER 500. REDUCTIONS IN AMOUNT TO SELLER 501. H •;- De nit see Ins ctiona 502. Settlement the ea to seller {line 1400) 503. Existing !Dens taken eubjeat to 504. Payoff of first mortgage loan 139,000.00 10,714.00 205. 555. Payoff of second m oRgege loan 820.00 508. Credrt for Tomtits Treatment 820,00 Ad stments • r Items un • id seller 210 C /town taxes 11. Cou taxes 212. sessmen 213. 214. 215. 216. 217. tg 01/01 to 08/03 15 2,933.31 508, Water Escrow Hold 509. Escrow HOLD for updated lien search A ustorents f items un oId salter 510. Ci /town taxes to 51 CGUnty taxes 280.00 5 00'.00 01/01 to 08/03 2 933.31 512, Aasesaments 813.2010 Prtroerty Taxes _ 614. Utilities Service Water #315163000418'4725947217 5 5. Sevtcaa Garbage, Trash & Storm Water 410753203094 518. Lot Cleartng Lien 6,824.35 60.14 4.493.41 5 423.97 517. Renew Electrical Permit #9104 -36 100.00 518. Code Enforcement admin fee d' 2000 -00742 519. 220. TOTAL PAID BY / FOR BORROWER 300, CASH AT SETTLEMENT FROM OR TO BORROWER 301. Grote amount due from borrower x. 120 302. LesS amounts , aid /for borrower 11 e 220 303. CASH FROM BORROWER 0603 -2011 at 3:09 PM 6,753.31 5 934.1 600. CASH AT SETTLEMENT TO OR FROM SELLER 140 880,53 801. 602. Less reduction amount due to seiier line 520 139,000.00 35,634.18 135 127.19 603. Page 1 013 103,365.82 1-!UD -1 #uo. Ar Weisel fee 805. Credit report 000. Tex ;entice ' 807. Flood.certifice8ort 808, 809. 810. 811. 812. 813. 814, ,,200. Items Required by Lender to Be Paid in Advance 901. ;tally Interest charges from to 90$. Mafiosos insummse premium f to 903. Homeowner's cnauranoc for to 904. 80$. 1000. Nerves Deposited with 1,Lnder 1001. Initial deposit for your escrow account (from GFg# ) mGF from GF from GFES3 from G (from CJFM) `trom GFE13t11 (from OFE 9J 100. Homeowner's Insurance me. a ft 41110. • 1003. Mo a fn fit a ma. r mo, $ 1004. city property taxes rte $ oar mo. $ 1(]05. County prOr�ett�teg x� mo. @ $ per mo. 3 9006. Anttuel Assette is mom Qtr mo. $ 1007. mo ar 1008. mo. l $ per mo. 3 5009. Aggrte Adlttstmerd 1100. Tltte G a es 1191. Title services end lenders title insurance $ OFl*4 1102. Settleme2/ or cdoplrq fee Ad Valorem Title oFEA 1103. rs t1Ue t nee Ad Valoreem'Rtle LLC (from GFEeS) 1104. Lender's title insurance Ad V�oram Title LLC 11 L1 L is tUYe Y RmJt 1106. Owners He poipy 8mit 139 900.00 -- 770.00 1107. rrre pci$on Of Me total tllfYe irtsuran Yxemis;m Ad valorem TItl� LLD 539.00 1108, Underwriters Rion of the total He Insurance rearm 3 231.00 1199. Title Search Tune Title _ (from GPM) 1110. Tax 6 Usti Soroh e City Lien Search (from OFE84L_ 1111, DYOUai Storage Fee Page/stream from GFE#4 1112. 1113. 10D. Government Recording and T sneer c es 1201. Gou mn-i rtt r000reing oharoas (from 0FE 7) 120P. heed 3 30.50 tdbrtgagQ _ efeases ; 120.00 1243. Transfer lamas 1204. Ice a s d $ 1205. State t,Otristamos deed $ 834.00 1208. intstn gfbie Tax Deed $ 120>. Mortgage $ 1208. _ 1300. Atigltianet settlement Charges 1301. rvlce 01st ou ran for 1392. 1303 1394, Mobile Closing Fee 1395, , °306. 1397. (from QFEiE08) 1400.. Total Battlement Cha r on 108 rstatetlon J send 2 Section K) I he OWn. ej to rte MUO-1 - -:.. ,., ..... ; beet of my'�oaiedge and geiier. It le a tee and accurate statement of all receipts �.o+di alcbur9emonts mean m rey ar,couit or by m6 hl Ihts ire kin. I h egrtSr at I teed b.mpe of the HUD. lament t / .ttYiw 1.880.50 19,714,00 The MOD -1 Settlement Stdam nit whidi e In eocOrderme prtapeted la 8 t uB 6r!d ru nxee semeunt of this ware:ven m t ramie ceased crowd( cause the funds to be dlatwser! Nis AVOUgl SRI 111 WARN :N(} die a crimp to linOWMply make tales etatentorito to the UAW Steles on tie or orq, other shnllar ram. pommies upon xnvictlon can %dude a fire or fmprt anent For *Mlle 884' Title t8 u S. Cede Swatch 1031 and Seddon 1010. 08-03 -2011 at 3:09 PM Page 2 of 3 HUD -1 ..L SETTLEMENT CIiARo"eES: Foe f�k�++ber. 11 -1373 700. Total Real Estate Broker Foos DlvIston of cornmfufptl (line 7001 as fallow: 4.170.0 to Re rs Fare lea 702 S 4.170.00 to R w Reefty , 703. Com tsslon Sefliom ant 704, 705. Transaction Pao Renter tpradise 000. Items n Gan tart wfth Lcin 8fl1, Our origfnatlan aharae $ tfrgm GFE 1) credit or a e ( tnt for the s ific inter t rate charm $ (from GFEi12) t1t33, Your odiWed ortyyirartion �tafes (from GFE Al PAID FROM PAID KRQM BORROWER'S SELLERS FUNDS AT FUNDS AT SETTLEMENT SETTLEMENT .340.01 203.rr Qhnrt ea -that Ca i Cf r _ tneAai deposit r your escrow account kIngest cha Homeowner's Insurance Loan Terms MEP " nee - 1,Uiv.vu _!79.60 TOTAL 1,900.50 1,630,0 Increase between GFE and HUD -1 Charges $ 0.90 or pee) Your initial loan amount Is Your Ican term is Your initial interest rate's Your Initlai monthly amount owed for principal, interest, and any mortgage insurance le Can your Interest rate rise? # 1001 Good FaftteEstlmate� HLIb-1 # 901 903 rdey,, year 0 �A s © Principal ❑ Interest ❑ Mortgage Insurance ® No. ❑ Yes, it can rise to a maximum of on and can change again every after Every change date, your Internet rate can increase or decrease by %. Over the lire or the loan, your interest rate is guaranteed to never be tower than % r h;g her then ❑ Yes It can a to a maximum of No. 0 Yes, the fast tncnease can be on awed can rise to $ The maximum It Can ever rise eels $ ® No. 0 Yee our maximum re ant n 15 27 No. ❑ Yes, you have a balloon payment of $ due in ® You do not have a monthly esorcw payment for items, such as property taxes anti homeowners Insurance. You must pay those items directly youraetf, ❑ You have an additional monthly escrow payment of $ that results In a total initial monthly amount owed of $ , This includes principal, interest, any mortgage Insurance and any Iternb checked below ❑ Property taxes 0 Homeowner's insurance ❑ Flood Insurance ❑ includes %. The first change will be Even if at: make a ante on i can our foan balance 7 N Even If you make payments on time, can your monthly amount owed for principal, interest, end mortgage insurance rise? Does your loan have a pre, d al ? Coes your loan have a balloon payment? Fti and the monthly amount Total monthly amount owed including escrow account payments ❑ ■ Note: If you have any questions ebout the Settlement Charges and Loan Terms Meted on this form, pies*? contact your lender, 08.03 -2011 at 3:09 PM Pege3of3 HUD -1 AppreLael fee 905. Credit report 00'8. Tax aerrice 'e 8 7. r ooq �lltfaa9on 809, 810. 811. 812. 813. 814. -- (from I FE #3) rom GFE03 Sfrom GrFE3) _. 0. Items Required by Lender to Be Feld in Advance 90•. alb: intarael charges from to 02. Mo r'IS�e insurance raremlurn fcr tp __2$ 903. Homeowner* insurance a for to 904. 0 . ' 1000. Reseryes Depoj tea with Lgndor 1001. Mei de Pos$ far y f account 100 . iomeawn S insurance „to, $ , =r no. 1003. 1%fortoa0e insur ncs mo. er mn, 10Qa. Cityp p(�erty taw 8 09r mo. $ 1005, CeunHpropertl` � - mo. $ perm. $ _. 1100e. Annual Assersemgnta mo per mo. $ 1007. m _ rnn Per mo $ 1 ' rmo. 1009. A99tgate Aaivstmertt S ,1150. Title Gt�art _ ��` 1101, Title services and I nder's title Insurmxs QF_, 11 mot or cto6Inq fee M valorem Pee LLD (from GFE#+) 1103. Qwsier's 1111e inag(rarrce Ad Vp oren' 7iue PLC (from GFE15) • 1104. Lender's titre insurance Ad Valorem Tltie tit; 11',, Lerde-'s tIlte polIcv limit 1105, Owner's title po(Gy limit 138,000.00 - 770.00 x1107. Agent's porton of 1J18 toter title !near mlwn A Valor®m T1tte LLC 1103, Undenuriter'3 otlion of the Mel title lnsurance premium 1 I9. TItIe $earth Tura Title 1�1 Q T�c� 'ere S+terth Cf L' arch �- 1111. DloNal Storage Fee Pat:eetrear (from GFE#4) 1112. - •fday (from t3Fi=#10}r (from f3nf?t__ rfrom GFEl*r 1 ti from GFEtt9 $ �ifrom 3FE#P4) (from GFE4114) 795.00 995.00 77p 0''T 539.00 _. '231.00 150,QQ 1113. 200. Gore ment R rain and ranafer char art 1201, Goterrnme t recording vh rges 1r6m (from t3FE041 30.04 1202. Deerii 35.50 35.5l -_Mortgagal_ ijeleases $ 120.00 1203. Transfer taxa) 1204. eV /county texhitemps Deed $ Mo11g$ge $ 1205. State OK/stamps Deed Tip 834.00 Mortgage 3 1206. 1ntanQ9bla Tex De- _ Mcm2gle $ (prom Q 1207. (from GROW, 1208. 1300. 11ipfttonal Setttgrnent Charges 1301. R quire r dca that ys ou t:an for 1302. 1303. 1304 Nlotdta CI Fee „1308. 1307. 1308, 375.00 120.00 $34.00 _ (from GFE#61 1400. Total Sett)emerat Dhat2 fentor on limes 103, Section J and 602, Seettion K). I ha = CBrefutlY ;e .' Q-1 ^ Ieme�ni 9F+t rtha l�a toot or my!<ncsrleaga endeBef. It 12 a true and aocureta statement of all reoelpu and d>Eburaemenl Made on my ercatP�t or lay me In eve P a .?,... On. I I' Wad a may of the i1 u0.1 +. lament St rRES`t. 1,880.50 1(0 ,714,(4!1 The [4WD -1 SBmmmentSalem/ant WW1 ill �n ametntf 7ta Ad t!; ^r r -.,r.6 revered red le 8 t'ua artd emirate account of thin Ironegatl!+n. I have aauaed *twat cE48 Ina funds to be dtetursai Data: Algoma Sid 2Q1.1 upon oemvialon amt Loci de a fine or impesonment. par dslah8 sew Title 18 u.s :ode Sacdon 1001 and Sealent101p y make false sleten+m,la to the United 6tete9 on (He or any ether ehnitar Tan, Fertdlllee 08-03 -2011 at 3 :09 PM Page 2 of 3 HUD -1 Property Information Report ,a lis e. My Home Property Information Report Summary Details: Page 1 of 1 MIAMI•D E) Folio No.: 11- 3101 - 024 -0070 Property: 9818 NW 1 AVE Mailing Address: KONDAUR CAPITAL CORPORATION ONE CITY BOULEVARD WEST STE 1900 ORANGE CA 92868- Property Information: Primary Zone: 0800 SINGLE FAMILY RESIDENCE CLUC: 0001 RESIDENTIAL - SINGLE FAMILY Beds/Baths: 2/1 Floors: 1 Living Units: 1 Adj Sq Footage: 1,251 Lot Size: 8,249 SQ FT Year Built: 1939 Legal Description: BONMAR PK A SUB PB 17 -11 S36.5FT OF LOT 17 & N36.5FT OF LOT 18 BLK 1 LOT SIZE 73.000 X 113 OR 14902 -674 0291 1 COC 25473 -4809 03 2007 4 Assessment Information: Year: 2011 2010 Land Value: $65,924 $65,924 Building Value: $94,763 $94,763 Market Value: $160,687 $160,687 Assessed Value: $160,687 $160,687 Taxable Value Information: Year: 2011 2010 Taxing Authority: Applied Exemption/ Taxable Value: Applied Exemption/ Taxable Value: Regional: $0/$160,687 $0/$160,687 County: $0/$160,687 $0/$160,687 City: $0/$160,687 _ $0/$160,687 School Board: $0/$160,687 $0/$160,687 Sale Information: Sale Date: 6/2010 Sale Amount: $100,000 Sale 0 /R: 27345 -0109 Sales Qualification Description: Corrective deed, quit claim deed, or tax deed; Deed bearing Florida Documentary Stamp at the minimum rate prescribed under Chapter 201, F.S.; Transfer of ownership where no doc stamps were paid; or, Transfer of ownership by other than a deed such as a final judgement or court order. View Additional Sales (Close window] jClick here to Printl This report was created on 10/17/2011 6:40:12 PM for reference purposes only. Web Site © 2002 Miami -Dade County. All rights reserved. http: / /gisims2. miamidade .gov /myhome /proptext_print .asp ?folio= 1131010240070 &cmd = 10/17/2011 RESIDENTIAL SERVICES CONTRACT i 5104UE12 CONTRACT /6 ' ' DATE ( / tf / CUSTOMER JOB LEAD �� /_ ACCOUNT NO / — � ®� S z NO �� SOURCE �.+ :.., i�fo " e >'. 3 r, .s .,'; „. ection 1. CustOi7ICYlI ADT Security Services, Inc MDT”) Office Address www.MyADT.com 1.800.ADT.ASAP® (1.800.238.2727) Customer Name (°Customer° or °I' or'me° or'°my°) fO L C�V� Ge�tsG /2" Address ° 6 L i �� f 14' Li6 ANN A o W Cityf� �l( S OP E5 i of "u� O � State O ZIP Tax Exempt No b a trn , thra Protected Premises' j ® Al 10/110/M Telephone Tax Expire Date 0 Traditional Phone ef Other (Qualified) 0 Other (Non - Qualified) Alternate ! Fo -3 • (( - 4 rf 67 Telephone 1 0 Home a Cell O Work IF FAMILIARIZATION PERI.s' ■ REJECTED INITIAL HERE f Alternate ! - Telephone 2 0 Home 0 Cell 0 Work (see Paragraph 14 of the Terms and Conditions for explanation) �y EMAIL g` O C, v 'S 144-11 J r 114 L. Co Communications Authorization: I authorize products and services to the contact infor 888.DNC4ADT (888.362.4238). Initial here ADT to provide me with information and updates about the security system and new ADT and third -party tiori r ided by me. I may unsubscribe or opt out by emailing donotcontact @ADT.com or by calling Confirmation of Appointments: I authorize appointments and provide other information ADT to call me using an automated calling device to deliver a pre - recorded message to set/conf' and notices about the alarm system at the telephone number(s) provided by me. Initial here • Alarm System Ownership: 0 Customer -Owned IOADT -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 AN13AGREE TA EACH AND`EVERY TERNIOFF I IS fCON'FRACT, INCLIJDING BUS NOT LIMITED TO PARAGRAPHS.5 AND 18 OF THE TERMS AND CONDITIONS. (B) THE I ,l I1AL TERM OF THIS CONTRACT IS THREE (3) YEARS. (C) ADT I5 NOT A SECURITY CONSULTANT AND CANNOT ADDRESS ALL OF MY PQTEISTIAJ- SECURITjf 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 NIS.1 HAVE $ELECTED AND PURCHASED ONLY THE EQUIPMENT AND SERVICES IDENTIFIED IN THIS CONTRACT. (D) NO ALARM SYSTEM CAN PROVIDPr COMPLETE PROTECTION OR GUARANTEE PREVENTION OF LOSS OR INJURY. FIRES, FLOODS, BURGLARIES, ROBBERIES, MEDICAL PROBLEMS AND OTHER INCIDENTS ARE UNPREDICTABLE' AND CANNOT ALWAY$ BE DETECTED OR PREVENTED BY AN ALARM SYSTEM. HUMAN ERROR IS ALWAYS POSSIBLE ,AO THE :_RESPONSE TIME OF POLICE. FIRE AND MEDICAL EMERGENCY PERSONNEL I5 OUTSIDE THE CONTROL OF ADT ADT MAY NOT RECEIVE ALARM CSI NALS.IF COMMUNICATIONS OR PQ,INER IS.INTERR.UPTED FOR ANY REASON. „ (E) ADT RECOMMENDS THAT 1 MANUALLY TEST'THE ALARM SYSTEM 1,110. : (LY.AND ANY TIME 1 CHANGE TELEPHQNE SERVICE, BY CAWNG 1.800.ADTASAP OR BY LOGGING IN TO W WW.MYADT.COM. (F) THIS CONTRACrREQUIRES FIN/(L 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 ADTS ONLY OBLIGATION WILL BE TO NOTIFY ME OF SUCH TERMINATION AND REFUND ANY AMOUNTS 1 PAID IN ADVANCE. ADT Representative Name J N r 2» -S /' c ,v C Rep. License No. Rep. ¢ �' (If Required) ID No. i' Customer s AppratLal: Original Signature Y -__ J Required (Must latch Customer Name in Section 1 above) ��' /f3 // i 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. FINANCIAL DISCLOSURE STATEMENT THERE IS NO FINANCE CHARGE OR COST OF CREDIT (0% APR) ASSOCIATED WITH THIS CONTRACT. A. NUMBER OF (712_9, �� tF % -/® PAYMENTS FOR THE B. AMOUNT OF EACH PAYMENT IS TOTAL OF PAYMENTS FOR THE INITIAL TERM IS INITIAL TERM 15 36. (TOTAL MONTHLY SERVICE CHARGE FROM BELOW) (A. TIMES B.) (EXCLUSIVE OF ANY APPUCABLE TAXES, FEES, FINES AND RATE INCREASES) LATE CHARGE - PAYMENT IS DUE PURSUANT TO MY SELECTED BILUNG FREQUENCY, PRIOR TO THE START OF SERVICE. MY FIRST BILL /CHARGE WILL BE SENT /MADE SHORTLY AFTER MY SERVICE BEGINS. ADT MAY. IMPOSE A ONE -TIME LATE CHARGE ON EACH PAYMENT THAT I5 MORE THAN TEN (10) DAYS PAST DUE, UP TO THE' MAXIMUM AMOUNT PERMITTED BY LAW, BUT IN NO EVENT WILL THIS AMOUNT EXCEED $5.00. PREPAYMENT - IF I PREPAY THE TOTAL OF PAYMENTS PRIOR TO THE END OF THE INITIAL TERM OF THIS CONTRACT, THERE I5 NO PENALTY OR REFUND. SEE SECTIONS 2, 7, 15 AND 19 OF THIS CONTRACT FOR ADDITIONAL INFORMATION ABOUT NONPAYMENT, DEFAULT AND ACCELERATION. 1 of 6 Administrative Copy ©2011 ADT. All rights reserved. (04/11)