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ELC-13-0518Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 187513 Scheduled Inspection Date: February 13, 2014 Inspector: Devaney, Michael Owner: , Job Address: 9723 NE 2 Avenue Miami Shores, FL 33138- Project: <NONE> Contractor: ADT LLC sunamg Department comments Permit Number: ELC- 3- 13-518 Permit Type: Electrical - Commercial Inspection Type: Final Work Classification: Addition /Alteration Phone Number Parcel Number 1132060134210 INSTALL ALARM SYSTEM Infractio Passed Comments INSPECTOR COMMENTS False 210 NE 98 ST Inspector Comments Passed Failed Correction ❑ Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. February 13, 2014 For Inspections please call: (305)762 -4949 Page 1 of 25 Miami Shores Village Building Department rT „ 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 J Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING Permit No. ,�- L- 3 -13-S18 PERMIT APPLICATION Master Permit No. FBC 20 Permit Type: Electrical OWNER: Name (Fee Simple Titleholder): C-4 Q� ® �L - 2 Phone#: Tenant/Lessee Name: Email: JOB ADDRESS: — - 3 NF, 2 QALQ City: Miami Shores County: Miami Dade Zip: (�Z Folio/Parcel #: 11 3 2 GG ®1:3 9 Z Is the Building Historically Designated: Yes CONTRACTOR: Company Name: NO Flood Zone: Address: p wT e e G zv City: StatdMS MARKS WAY Zip: Qualifier Name: M6RAMAR, FL 33025 Phone#: State Certification or Registration #: G T LY–JU < < L \ Contact Phone#: Email Address: DESIGNER: Architect/Engineer: Certificate of Competency #: Value of Work for this Permit: $ Square/Linear Footage of Work: Type of Work: OAddrfss ❑Alteration ❑New ORepair/Replace ❑Demolition Description of Work: �e ° A Submittal Fee $ Permit Fee $ 0,00 CCF $ CO /CC $ Scanning Fee $ `3- C)? Radon Fee $ DBPR $ Bond $_ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ 1 Q 3 Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip 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 MPROVEMENTS 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 properly 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 Owner or Agent The foregoing instrument was acknowledged before me this day of , 20 _, by Signature ontractor The foregoing instrument was acknowledged before me this day of , 20 13, by k CC4 ffr-W ° who is personally known to me or who has produced who is personally known to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: • ay,,, ;;,., ���oc,,,f�,.A3TR0 My Commission Expires: My Commission Expir fs�.., , _ .:E,_ �:�e, i.iG!1�rQ I�I�Uic�l3�y�i 'c;iicllnBnn+mt�r APPROVED BY l ° �G Plans Examiner Zoning Structural Review Clerk (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) Miami Shores Village Building Department 4 �� 10050 N.E2nd Avenue, Miami Shores, Florida 33138 Teh (305) 7952204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 it r'p FBC 20 BUILDING Permit No. et- [ `�- PERMIT APPLICATION Master Permit No. Permit Type: Electrical JOB ADDRESS: 7240 V3- City: �Mh Folio/Parcel #: ._ 1- Is the Building Historically Designated: Yes County: Miami Dade Zip: NO v Flood Zone: OWNER: Name (Fee Simple Titleholder):`` mo=t✓ _, C]%�rnonew: Address: 1� � � %lO� `7t City: ` kkaw i7 C�(1 _ , ,State: Zip: )Kcz Tenant/Lessee Name: Email CONTRACTOR: Company Name: WIT L-L t Phone #: Address: �(��- a�'Ll� W W\ City: z1 C) L, Qualifier Name: N­3-1- 314_;Q�L F"W�'�Xjk l<C rnonefF: _ State Certification or Registration #: C'�- IIZA Certificate of Competenc #. Contact Phone #: '5-247 Email Address: ff\ R `P DESIGNER: Architect/Engineer: Phone #: Value of Work for this Permit: $ 1 Square/Linear Footage of Work: Type of Work: ❑Address ❑Alteration Description of Work: 1-y ZpNew ❑Repair/Replace ❑Demolition Submittal Fee $ 0 4Mn Permit Fee $ f 10 CCF $ CO /CC $ W-AW VW Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ DBPR $ Bond Technology Fee $ TOTAL FEE NOW DUE $ Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip 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 MPROVEMENTS 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 $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Owner or Agent The foreggg ins went was acknowledged before me this' � day of y , 20 by )C1!0,-_'& I�e a�§� ' ► who is personally known to me or who has produced As identification and who did take an oath. Signatu Contractor The foregoing instrument was acknowledged before me this day of , 20 � �i by (e. QLICI �,l who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: ,.®� 1 #1 100 � Sign: Sign: Print: �1 r� p`� %� 7® N� 1ZgvGH M. 4 Print ,v. • •. o RUIMALANWIf ,C ': ND - s—uc i wRt��RS; ` My Commission Expires: * * W ISWIHE8 d 3017 My Commission Expires: ,� :;,t;� ®� .` ;���< ®•.C�'3...... s e� AgG ��������P9jt$ 1$ 19$ s�il1af�aiji �l�t�$ t7$$ t�Siki�tljtA�$ p�1�7���IC�iC�A47��7I���� %I��N�k����i • k�k% B�H��k�k��MM�b�k��k% N% k�N�k�k�k�N��% k% b��k�k��k�k�k��k���k�� %�N����N�%$���b�R�N�kA�����04�@ APPROVED BY �/� ��'/�(�/Z Plans Examiner Structural Review (Revised 3 /12/2012)(Revised 07 /10 /(Y7)(Revised 0&10/2009)(Revised 3/15/09) Zoning Clerk I Property Information Map Page 1 of 1 Property Information Map Aerial Photography - 2012 0 114f, This map was created on 2/26;2013 4.41:10 PM for reference purposes only. Web Site © 2002 Miami -Dade County. All rights reserved. ' Sumrnary Details: Pronerty Information: 100 COMMERCIAL - roe . 723 NE 2 AVE ailing IGATOR 9723 NE 2ND AVE ddress: ILLC Floors: 595 NE 163 ST NORTH k162- _ivinq Units: IAMI BEACH FL di Sq Footage: 9,459 Pronerty Information: Assessment Information: Year: 100 COMMERCIAL - Primary Zone: EIGHBORHOOD CLUC: 11 RETAIL OUTLET 11", Beds /Baths: /0 Floors: _ivinq Units: 0 di Sq Footage: 9,459 Lot Size: 12,350 SQ FT Year Built: 1948 IAMI SHORES SEC 1 MD PB 10 -70 LOTS 10 Legal 11 BLK 31 LOT SIZE Description: 5.000 X 130 OR 17437- 1378 1196 4 (2) OR 8412 -2519 1212 01 Assessment Information: Year: 2012 2011 Land Value: $247,000 $247,000 Building Value: $347,740 $347,740 Market Value: $594,740 $594.740 ssessed Value: $594,740 $594.740 Taxable Value Information: Year: 2012 2011 Taxing Authority: Applied Exemption/ Taxable Value: Applied Exemption/ Taxable Value: Regional: $0/$594,740 $0/$594,740 ount : 1$0/$594,7401 $0/$594,740 12ity: 0/$594,740 $0/$594,740 School Board: 1$0/$594,7401$0/$594.740 Sale Information: Sale Date: 12/2012 Sale Amount: $594,800 Sale O /R: 8412 -2519 Sales Qualification Description: Sales qualified as a result of examination of the deed View Additional Sales .. r ;.—;,I. A, ,Tiiii /1- n \il)ni- ne/„rintii -ign a.,n?mantirl= httn: / /Isisims2.miamidade.�-yo... 2/26/2013 ­AAAfw.sunbiz.org —Department of State Home Contact Us E- Filing Services Previous on List Next on List Return To List No Events No Name History Detail by Entity Name Florida Limited Liability Companv GATOR 9723 NE 2ND AVE, LLC Document Searches Pate 1 of 2 Forms Help Entity Name Search Submit This detail screen does not contain information about the 2013 Annual Report. Click the'Search Now' button to determine if the 2013 Annual Report has been filed. Search Now j Filina Information Document Number L12000146623 FEI /EIN Number NONE Date Filed 11/21/2012 State FL Status ACTIVE Effective Date 11/20/2012 Principal Address 1595 NE 163RD STREET NORTH MIAMI BEACH FL 33162 US Mailing Address 1595 NE 163RD STREET NORTH MIAMI BEACH FL 33162 US Registered Agent Name & Address GOLDSMITH, JAMES A 1595 NE 163RD STREET NORTH MIAMI BEACH FL 33162 US anager em er Detail Name & Address Title MGR GOLDSMITH, JAMES A 1595 NE 163RD STREET NORTH MIAMI BEACH FL US Annual Reports No Annual Reports Filed Document Images httD :Hsunbiz.orp-/scrit)ts /cordet.exe ?action= DETFIL &ina doc number— L12000146623 &in... 2/26/2013 ,wkvw.sunhiz.org - Department of State 11/21/2012 — Florida Limited Liabilityw Previous on List Next on List Return To List No Events No Name History I home I Contact us I Document Searches I E- Filincl Services i Forms I Hek) I Cotivrioht `St and Privacy Policies State of Florida, Department of State Page 2 of 2 Entity Name Search Submit bttn : / /sunbiz.or� /scrints /cordet.exe ?action= DETFIL &inq doc number= L12000146623 &in... 2/26/2013 W�vv .stznbi5.org - Deliartment of State Home Contact Us E- Filing Services Previous on List Next on List Return To List No Events No Name History Detail by Entity Name Florida Limited Liabilitv Company GATOR 9723 NE 2ND AVE, LLC Document Searches Forms Page 1 of 2 Help Entity Name Search Submit This detail screen does not contain information about the 2013 Annual Report. Click the 'Search Now' button to determine if the 2013 Annual Report has been filed. Search Now j tiff t +' 1 • • ` Document Number L12000146623 FEI /EIN Number NONE Date Filed 11/21/2012 State FL Status ACTIVE Effective Date 11/20/2012 Principal Address 1595 NE 163RD STREET NORTH MIAMI BEACH FL 33162 US Mailing Address 1595 NE 163RD STREET NORTH MIAMI BEACH FL 33162 US Registered Agent Name & Address GOLDSMITH, JAMES A 1595 NE 163RD STREET NORTH MIAMI BEACH FL 33162 US Manager /Member Detail Name & Address Title MGR GOLDSMITH, JAMES A 1595 NE 163RD STREET NORTH Mli %J.11 BEACH F:. "62 US Annual Reports No Annual Reports Filed Document Images httn• / /ciinhi7 nru /crrintc /c�nrriPt Pxee'?ar.tion= DETFII, &ina doc number— L12000146623 &in... 2/26/2013 ' \NNv •.fiunbiz.org - `Department of State Page 2 of 2 11/21/2012 — Florida Limited Liability View Image in PDF format Previous on List Next on List Return To List Entity Name Search No Events No Name History . Submit Home ( Contact. us j Document Searches I F- Filing Cot)vriciht and e'riva, sii[ict5 State of Florida, Department of State httn• / /ennhiv nry /crrintc/t-nrrTPt aYP ?a(-.tinn= T)RTF11.&.ino doc number— L12000146623 &in... 2/26/2013 Property Information Map Page 1 of 1 Property Information Map Aerial PhotoOrachy - 2012 0 114 fl This map was created on 2i2612013 4.41.10 PM for reference purposes only Web Site © 2002 Miami -Dade County. All rights reserved. Summary Details: Prnnartu Infnrmatinn: 100 COMMERCIAL - Primary Zone: 723 NE 2 AVE ailing GATOR 9723 NE 2ND AVE ddress: C Floors: 595 NE 163 ST NORTH _ivinq Units: IAMI BEACH FL 'kdj Sq Footage: 162- Prnnartu Infnrmatinn: AQQPCCment Information: Year: 100 COMMERCIAL - Primary Zone: EIGHBORHOOD CLUC: I,", 11 RETAIL OUTLET Beds /Baths: /0 Floors: _ivinq Units: 0 'kdj Sq Footage: 9,459 Lot Size: 12,350 SO FT Year Built: 1948 MIAMI SHORES SEC 1 MD PB 10 -70 LOTS 10 Legal & 11 BLK 31 LOT SIZE Description: 5.000 X 130 OR 17437- 118412-2519 3781196 4 (2) OR 1212 01 AQQPCCment Information: Year: 2012 2011 Land Value: $247,000 $247,000 Building Value: $347,740 $347,740 Market Value: $594,740 $594,740 Assessed Value: $594,740 $594,740 Taxable Value Information: Year: 2012 2011 Taxing Authority: Applied Exemption/ Taxable Value: Applied Exemption/ Taxable Value: Regional: $0/$594,740 $01$594,740 Coun tv: DO/$594,7401 $0/$594,740 City: 1$0/$594,7401$0/$594,740 chool Board: $0/$594,740 0/$594,740 Sale Information: Sale Date: 12/2012 Sale Amount: $594,800 Sale O /R: 28412 -2519 Sales Qualification Description: Sales qualified as a result of examination of the deed View Additional Sales I . I .. 1= httn: / /P-isims2.miamidade.f o... 2/26/2013 II -hr- SMALL BUSINESS CONTRACT CONTRACT / ACCOUNT NO , DATE NOEL] SOURCE Section • into ADT LLC I Business Name dba ADT Security TFM Y Services (Customer' or "I" or "me" or "my") Office Address i Premises' — t � � C Address ;' �' �. City j M` State m ZIP ) I Responsible Party Name www.MyADT.com 800.ADT.ASAP® Protected Premises' ( 1 . - Qualified) Traditional er a (800.238.2727) Phone (Required) 10 Fill in if billing address is the same Billing Address m Billing Phone city State ZIP (Required) IF FAMILIARIZATION PERIOD IS REJECTED INITIAL HERE (see Paragraph B3 of the Terms and Conditions for explanation) _ ... . ............ . ....... . .......... . �_....__ EMAIL - �! (�C' -�. 1,\ 111.ol � � i, aCA , f�' � vl" > � y � .: _.J_..7 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 ................. .......... __ ....... _._ ._....- ._.. ------- - - . ... __._ If I have provided ADT with a phone number, including but not limited to a cell phone number or a number that I later convert to a cell phone number, I agree that ADT may contact me at this number. I also agree to receive calls and messages such as pre- recorded messages, calls and messages from automated dialing systems at the number(s) provided. Ownership of System and Equipment: O Customer -Owned sO ADT - Owned Verticals O Retail O Business Services O Personal Services O Automotive/Transportation W,Grocery /Food O Health Services O Restaurants O Wholesale O Other 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 C and E of the important terms and conditions. (B) The initial term of this Contract is three (3) years: (C) 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. (D) ADT recommends that I manually test the alarm system monthly and any time I change telephone service, by calling 800.ADT.ASAP. (E) 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. -- ._....._... _ ........ ... ...... _ _ ........... -- -- ------- 11 ................. - ....... _.__.._ ._...._.... .... - ....... _ ...... .. - - -- .._._.._........ .__..._.__......... -- ... ........... — - ---- -..... - - - -- - -- ..._ _. . ADT Representative Q f (— t Rep. License No. Rep. l - � IV 1 I (If Required) ID No: pp ( r Custome`` Original Signature Required NOTES (Special Instructions /Directions /Cross Street) s 1 02012 ADT LLC dba ADT Secu ity Services. 1 Of 6 Adininistrative Copy Al! rights ra: - _rvad.. (': Oil 2 0 SMALL'BUSINESS CONTRACT �N�NIINNIiIUI'II�IIiiiV LEAD CONTRACT( �/© ACCOUNTMNO NO m SOURCE �ID DATE O Check received for: O Installation: Check # O Annual Service Charges Collected: Check # ._ ....... _ ....... — ----- -- - _......_....- - - -- _____..-.__..__ ..... ........ .._.._...... _ ....... ... .._....,. I authorize ADT: O To withdraw all (i) Service Charges and (ii) Contract Termination Charges (see Paragraph C. 2 Term and Payments) from my bank account: O Annually O Semi - Annually O Quarterly O Monthly Choose one: O Checking O Savings Name of Bank/Credit Union a�4sr a�yk +yW�ksaaw +aN tK..rw+tw+yw + ✓Na"laa+yrx + ?zaki � +� �+w'S �+a*S°{�+a� ,,,, �i'"thr�Ir.�Nr7r'!'lyr�r�.Fkh r.'*ky Recurring Service Charge Amount Plus tax Name as it appears on bank account I authorize ADT to debit my bank account for the amount of all Recurring Service Charges and all Contract Termination Charges (see Paragraph C. 2 Term and Payments) indicated above. I may revoke this authorization only by 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. Amount $1 11111 1 1 Amount Check Confirmation # Check Confirmation # O To charge my credit/debit card for all (i) Service Charges and (ii) Contract Termination Charges (see Paragraph C. 2 Term and Payments): O Installation O Installation Deposit Only O Remaining Install Balance Only O All /Recurring Service Charges O Annually O Semi- Annually O Quarterly O Monthly O VISA O MasterCard O Discover O AMEX Credit/Debit Card Number Expiration Date 'loss 111 v_M Recurring Service Charge Amount Cardholder's Name If I am using a debit card, I authorize ADT to debit my bank account for the amount of all Recurring Service Charges and all Contract Termination Charges (see Paragraph C. 2 Term and Payments) indicated above. I may revoke this authorization only by notifying ADT and my bank in writing at least 10 business days before the scheduled debit. 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, or if Contract Termination Charges (see Paragraph C. 2. Term and Payments) apply, 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 s l O Annually O Semi- Annually O Quarterly O Other DOA Approval ; If no oval is filled, ADT will send bill quarterly. National ACCOI Manager ID Cross Street Municipality Municipality Police Name I I I I I I I I I I I I I I I I I Fire Name Job Type O New Sale O Changeover O Resale O Upgrade Control Type O HW O RF Resale- Former Acct # Former CS # y Resale- Former Acct # Former CS # This password must be issued to all users of the alarm system, including all people listed in Section 7. An optional, secondary password 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 calling AD.T toll -free at 800.238.2727: 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, these individuals may be called prior to notification of the authorities. the password, and the keypad code. By selecting the "Yes" designation on the right I am identifying which of Customer/Emergency Contact #1 r( f:r•, lj , r. °l� )' �}C Phone O Home O Cell O Work • Yes .O No .? Print First/Last Name O O O 00 Phone Customer/Emecgency Contact #2 f a aj (, ) )'' ` Home O Home Cell O Cell Work O Work Yes YO es No O No Print First/Last Name '\ Phone O O O 00 Phone Home Cell O Work O Yes 00 No Alternate /Emergency Only Contact Phone Home Cell Work Yes No Print First/Last Name O O O O O Phone Home Cell Work Yes No 02012 ADT LLC dba ADT Security Services i O l S All rights reserved. (10/12 ,S�UTALL BUSINESS CONTRACT 111111 11111 11111 11111 1111 1111111 1111 11111 1111 lill 54000E02 t. CONTRACT LEAD DATE / ACCOUNT NO �� ,NO m SOU CE 'II�JIh� II � [ L�J 'Alarm Monitoring and Notification Services A Burglary (BA) O Hold -up (HUA) Duress � O Two -way voice __.._...... . ..._ . .. _ ... ._ . .__ ....... .................... O Critical Condition Monitoring (CCM) O Flood O Temperature O Parallel Protection O ADT DataSource O Open /Close Login 10 Supervised Scheduled Open /Close Monthly Service Charge Monthly Service Charge On Site Services I O Guard Response O Interior O Exterior - ........ -......... ...... _ .......... ....... _ _ ._._.. _.. .. -- - -- - ...... - _ 1 ..._ . - .. O Other Total Monthly Service Charge, . .......... ........... _. 1111... . 111. ... _ _ __ ........... 1. ... .......... _ ........... _1111.. . Initial Fee O Annual UL Certificate Fee Q ADT to obtain Electrical Permit Municipal Electrical Permit i t O Customer to obtain and pay for initial /annual municipal alarm use permit. Failure to obtain and provide ADT with the municipal alarm use permit registration number could result in no municipal firelpolice response to an alarm from the premises and/or a fine. O ADT Entry Solutions j O Other j Other Services Quality Service Plan (QSP) i s `, t ....... _ .................. ....... __. _.. ............ ................ .. ...... _.......... Installation Price Taxable Amount (Leave blank of ADT - Owned) .. _ .. _1111. .... . ..... .... __ ....,11.11 . _1111 ... . ......... ........_.._.... ..,........ O If Quality Service Plan (QSP) is Declined Customer 1.1.1...1........ _.......... Non - Taxable Amount (Leave blank if ADT - Owned) must Initial here O Preventative Maintenance /Inspections Per Year . 01 02 03 04 06 012 j - - -- - -- - - - -... ................... _ .... _. .... _ ............. _ ..... O Training ...1.111. ...;1111... ......... ........................ .... .... .... ... ..... . ... .... .... ... . O Direct Connection Services I$ O Monthly Recurring Municipal Fee (Subject to change based on local law) 7111M Tax Expiration Date O Customer to obtain and pay for municipal alarm use permit *If applicable sales tax not shown, it will be added to the first invoice, if not collected. at the time of installation. ....... _ .................. ....... __. _.. ............ ................ .. ...... _.......... Installation Price Taxable Amount (Leave blank of ADT - Owned) I 1.1.1...1........ _.......... Non - Taxable Amount (Leave blank if ADT - Owned) I$ Connection Fee . ..._ . - ..... . --- - - -... . __..._ ... -- Sales Tax on Installation* . .. ...._ Tax No. Tax Exempt, 7111M Tax Expiration Date - . __ 1111, __._._. Total Installation Charge* Deposit Received: 100% deposit required < $500 Minimum 50% deposit required $500+ O Money Order O Check. O Credit/Debit Card ; -- Balance Due* 02012 ADT LLC dba ADT Securitl Se- ices. 4 All rlghts reserve;;. 00/12) "'