HomeMy WebLinkAboutBuilding Permit #912 - 90 BLUE RIDGE ROAD 6/19/2012TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION p�
Permit NO: (L Date Received]461
Date Issued:
IMPORTANT: Applicant must complete all items on this
04
Print
PROPERTY OWNER \)ov\ Unit #
Print
MAP NO: PARCEL: ZONING DISTRICT: VZ Historic District yeOno
Machine Shop Village ye100 year-old structure ye
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
00ne family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
i17 Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
q septrc; Welly
1 91 Floodplaini W�Wet
QisffrU
` O'Water/Sewer
`
DESCRIPTION OF WORK TO BE PERFORMED:
eTA6 L_ \\ w\.r, �- A Ani rs C
I D S�
(Identification Please Type or Print Clearly)
OWNER: Name: `�, _C e_ J CA \`-Iy 4 Phone:
AddressAu a\
e_
�8
CONTRACTOR Name:
✓\ Phone:SUf-3 Dacf o x
Address: vl, b a}
910.1.
Supervisor's Construction License: 9 S_�b 1- Exp. Date:
Home Improvement License: I �-b )9,l O Exp. Date:
ARCHITECT/ENGINEER
Address:
Phone:
.N
1 a -a3-13
FEE SCHEDULE. BULDING PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 3 ''2)011 , v v FEE: $ 0
Check No.: ac) 3 R � I Z7 __-� 12,-Z, Receipt No.: aN ,z 2_ -
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature:ofaAgenVOvvneF Signature�oftcontractor
Location &etf'
v
No.— Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee
Other Permit Fee
TOTAL
Check 4r) o 1 2-z 1-?,
25432 Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ '
Tanning/Massage/Body Art ❑
Swimming Pools ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENT
CONSERVATION
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
FIRE DEPARTMENT - Temp Dumpster on site
Located at 124 Main Street
Fire Department signature/date
COMMENTS
yes.
Located 384 Osgood Street
no
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
Doc:.Building Permit Revised 2011 June/mi
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition or Decks
❑ Building Permit Application
❑ Certified Surveyed .Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: Doc.Building Permit Revised 2008mi
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�- Massachusetts - Dcpanmcnt of Public �ActN
Board of Buildin-, Re-,ulations and titand:u d>
Construction Supervisor License
License: CS 95707
BRIAN DENNISON
86 CREST CIRCLE b
WORCESTER, MA 01603 f'1
Expiration: 9/8/2012
( mniiai ncr Tr#: 2622
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D -\ Office of Consumer Affairs & BdsinessRegulation
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HOME IMPROVEMENT CONTRACTOR
Registration: 70810
Expiration: ,:12/2013 Type: 3/2
Corporation
R �WAL BY ANDER:SENCORP.ORATION
BRIAN DENNISON,
104 OTIS ST.
NORTHBOROUGH,
Undersecretary
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GERiIF CA` E OF LiABIL( INSURANCE
DATE(MMfOOIYt'1'Y)
01/11/2012
THIS CERTIFICATE 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 -DR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORiEED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the Certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of.the poiicy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate hoider in Lieu of Such endorsement(s).
PRODUCER 1-612-333-3323
Hays Companies
CDNTACT Jonelle Hargrove or Eatie Psimos
NAME
PHONE 612-333-3323 a ,No:612-373-7270
A1C Nn
E-MAIL
ADDRESS:
BD South St --h Street
PRODUCER
CUSTO RID k.
Suite .7DO -
Minneapolis, MN 55402
INSURERS AFFORDING COVERAGE NAIL {,
INSURED
INSURER 4 : OLD P,SPUELIC INS CO 24147
INSURERB: NATIONAL UhTTION FIP.R INS CO OR PETTS 19445
Renewal By Andersen Corporation
INSURER C:
104 Otis Street
INSURER D:
INSURER E:
r3arthbaraugh, MA 01532
INSURER F: '
ocI IADr7 RFVICIrlkl MIIMRPR'
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.
INSR
LTR
TYPE OF INSURANCE
ADDLSUBR POLICY EFF .POLICY EXP
INSRPOLICY NUMBER (MM/DD MMIDD
LIMnS
A
GENERAL LIABILITY
M MY 59313
3-0/01/2-:'
10/01/12
EACHOCCURRENCE S 1, DDD, DOD
PREMISES (Ee occurrence
X COMMERCIAL GENERAL LIABILITY
MED EXP (Anyone person) $ 10 , D OO
CLAIMS -MADE OCCUR
PERSONAL 8 ADV INJURY S 1, 000, D O D
GENERAL AGGREGATE S 4,000,000
GEN'L AGGREGATE LIMIT.APPLIES PER
-
-PRODUCTS - COMPIOP AGG S 3 , O D 0 , D 0 D
S
'
X POLICY PR6 LOC
A
AUTOMOBILE
LIABILITY -
MR'TB 21377
10/()1/1
10/01/12
COMBINED SINGLE LIMIT $.3,000,ODO
(Ea accident)
X
ANY AUTO
BODILY INJURY (Per person) $
BODILY INJURY .(Per accident) $
ALL OWNED AUTOS
PROPERTY DAMAGE -
(Peraccident) S
v
SCHEDULED AUTOS
HIRE' -D AUTOS
S
X
NON -OWNED AUTOS
S
B
R
UMBRELLA LIAB
X
OCCUR
2503D519
10/01/1
10/01/12
EACH OCCURRENCE S 25,000,000
AGGREGATE S 25,000,000
EXCESS LIAB
CLAIMS -MADE
DEDUCTIBLE
S
S
X
RETENTION S 2S, ODD
p
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETORIPARTNERIEY.ECUTIVE
OFFICERIMEMBER. EXCLUDED? N
(Mandatary in NH)
N / A
MWC 117140 00
10/01/1
10/01/12
X WC'I WI 0TH -
EL EACH ACCIDENT S 1, ODD, DDD
E L DISEASE -EA EMPLOYEES 1, LIDO, DOD
E.L DISEASE -POLICY LIMIT $ '-,()Do, D O D
It yes, describe under
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (AHaeh ACORD 1 Dir Addifional Remarks Schedule, r more space is required)
DN i.demee of .Insurance.
L�t:K I V_ILEA I t .I" LJLLl=rl
SHOULD ANY DF TTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFDRE
Bmidence of Insur=.nce THE .EXPIP-knDN DkTE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WrM THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
.2�5»os 51966-GU0 AL:UtCU LLJrrVtcAirut%. r+u Iryurs ICJCIYC4.
k:CORD 25 (20Q9/Q9) The ACORD name -and logo are registered market of ACORD
25114267
The Coli mortwealth of Massachusetts
Department of Industrial Accidents
office of Investigations
a 600 Washington Sheet
Boston; M4 U2111
if".mass.gavfdia
Workers' Compensation Insurance Affidavit: Btilders/Contraetors/ Nectricians/ l tubers
A Iicaat Information Please Frint_Le€ribl r
Name (Business/organization/Individual);
City/State/Zip: r\c)jry2(
r
lire you an employer? Check the appropriate beg:
1,.Q I am a employer with D 4. ❑ I am a general contractor and I
employees (full and/or part-time), T
have hired the sub -contractors
listed on the attached sheet $
2. ❑ I am a sole proprietor or partner-
ship and have no employees
These subcontractors have
working for me in any capacity,
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
officers have exercised their
required ]
3. ❑ I am a homeowner doing all work
.
right of exemption per MGL
myself. [No workers .camp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
-comp. insurance required.]
Type of project (required):
6. ❑ New construction
7.. [ 4Z=odeling
8, /❑ Demolition
9. ❑ Building addition .
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ other
`Any applicant that ch=ks box #1 must also ED out the section below showing their warktrs' compensation policy information,
I $omeowners who submit this afndavit indicating they are doing all work and thm hire outside contractors must submit a new affidavit indicating such
�contcacton that check, this box must attached an additional sheet showing the name of the sub-contrac tors and their workers' comp. policy information.
I am an.empioyer that is providing wort�..ers' compensation insurance for my employees. Below is fixe policy and job site
ii forPFLatGvFL. `` I
Insurance Company Name:_ l (� .Q O`,A\ C f� S C
Policy # or Self ins. Laic, #: } ' 1 Expiration Date:
Job Site Address: ►J.� E'_ G city/State/Zip: O1
l _ttach a copy of the workers' compensation policy declaration gage (shaving the policy number and ezgiration nate).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ne up to 1,SQ0.00 and/ne
or o -year imprisonment, as well cive f
il penalties in tharm of a STOP WORK ORDER and
fiat a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded.to the Ou`^ce of
Investigations of the DIA for insurance coverage verification.
I do hereby .eer dfy u •'the pains�penatties of perjury that the information provided above is V -u and correct
Si�ature; it Date:
Phone #:
Official use only. Ifo not write in this area, to be completed by city or towil official
City or Town:
permif/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department S. City/Town Clerk 4. Electrical inspector 5. Plumbing inspector
.6. Other
Contact Persoa: Phone P
Renewal
byAndersen.
WINDOW REPLACEMENT an Andersen Company
Buyer(s) Name
R._--wal by Andersen Corporation MA Home Improvement Contractc
104 Otis St., Northborough, MA 01532 License # 170810 (Expires 12/23/201:
(508) 351-2200 • Fax: (651) 351-4810 Federal Tax ID #41-191841
WINDOW SPECIFICATION SHEET
Date of
The Buyer(s) listed above hereby jointly and severally agree to purchase the goods and/or services listed below, in accordance with the prices and terms
described on the Specification Sheet and the front and the reverse of the accompanying CUSTOM WINDOW AND DOOR REMODELING AGREEMENT,
of which this Specification Sheet is a part.
WINDOW DETAILS
1. Contractor will Install a total of windows in Owner's home, using the following individual quantities:
Double Hung (DB) K Equal sash ❑ Cottage sash (1/3 top, 2/3 bottom) ❑ Oriel sash (2/3 top. 1/3 bottom)
Casement (CW) ❑ Hinge right ❑ Hinge left (as viewed from exterior): ❑ Standard handle ❑ Metro handle
Double Casement (CDW) ❑ Standard handle ❑ Metro handle
Casement / Picture / Casement (CPW) ❑ 1:1:1 or ❑ 1:2:1 ❑ Standard handle ❑ Metro handle
2 Lite Gliding Window (GW)
Glider / Picture / Glider (GPW) F1 1:1:1 or ❑ 1:2:1
Awning Window (AW) Pli;tRePindow (PW)
Bay or Bow Window Doors (see separate Door Specification Sheet)
2. Yes ❑ No Qty of Windows to be Custom Fit Replacement:
3. Yes No Qty of Sills to be replaced by Contractor:
4. ❑ Yes RNo Qty of Windows to be New Construction Full frame (includes new interior & exterior casings) and actual
Exterior casings: ❑ Pine ❑ Maintenance -free material ❑ Factory applied 908 Fibrex brickmold
5. Glazing to be: M HP Low- E-4 TM ❑ Other If other, please specify:
6. Exterior color to be: R White ❑ Sand ❑ Canvas ❑ Terratone ❑ Cocoa Bean
7. Interior color to be: [9 White ❑ Sand ❑ Canvas ❑ Terratone ❑ Pine ❑ Maple ❑ Oak
Note: Interior color can only be white, wood or same color as exterior. Wood interiors need to finished by Owner.
8. Hardware: UK White ❑ Stone ❑ Canvas ❑ Brass ❑ Estate Hardware: Style:
9.9 Yes ❑ No Install Lifts with Double Hung Windows
I creens: windows to have: ❑ Half or K Full screens Screens to be: Fiberglass ❑ Aluminum ❑ TruScene
GRILLE DETAILS
1 I . Windows have grilles: 4 Yes ❑ No If yes ] Grille Between Glass (GBG) ❑ Removable Interior Wood (wTm ❑ Full Divided Light (FDL)
Qty: Qty: Z Qty: Otv: ()tv 3 nr
om
w grille patterns above *Use additional sheet if needed Owner approved
ADDITIONAL WORK DETAILS
I Z. LJ Yes t4 No Contractor will remove metal frames of windows. Qty of Units:
13. ❑ Yes [g No Contractor will install new paint -ready or stain -ready casings.
Interior casing qty of openings: Exterior casings qty of openings: ❑ Pine ❑ Maintenance -free material
14. ❑ Yes 0 No Contractor will install new paint -ready or st ' e or outside stops qty of openings:
Interior stops qty of openings: Exteri stops qty of ope ings: El Pine ❑Maintenance -free material
15. Owner is aware that Contractor does not do any p� • er Initials
16. ❑ Yes 'Z No Contractor will wrap exterior casings with aluminu cot stock of color.
Note: Wrapping may be required with storm window remova ; removal of storm windows will leave screw holes in casing.
17. Yes ❑ No Contractor will insulate, caulk and seal windows with 3 -point system to prevent water and air infiltration.
18. Yes ❑ No Clean up all job related debris including old windows will be removed. Vacuum nightly.
19. Yes ❑ No. A limited warranty shall be issued to Owner upon completion of the job and payment in full.
20. 09 -Yes ❑ No BuildinPermit—Contractor will secure any and all necessary permits. The fee for the permit(s) is not
included in the Contract Price and a separate check is required at the time of sale for this fee.
21.0�Yes ❑ No All discou is ha vf been aPFlie to this agr eme t price.. /
22. Additional job details: t moi! VCM
�/IOj2��
23. U Yes ❑ No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment.
No final payment shall be demanded until the contract is completed to the satisfaction of all parties.
It is agreed and understood by and between the parties that this Specification Sheet, along with the CUSTOM WINDOW AND DOOR REMODELING
AGREEMENT, constitutes the entire understanding between the parties, and there are no verbal understandings changing or modifying any of the
terms. This Specification Sheet may not be changed or its terms modified or varied in any way unless such changes are in writing and signed by both
the Buyer(s) and Contractor. Buyer(s) hereby acknowledge that Buyer(s) has read this Specification Sheet.
nel& g^rsen Corporation Buyer B
•'II �
`"re'gaf. ��M�.nag�ger/
ofProduct Manager Print N "e
uyer(s)
Signature
Print Name
RenewalMA Home Improvement Contractor
bYAndersen. J `'License #170810 (Expires 12/23/2013)
WINDOW REPLACEMENT an Andersen Company Renewal by Andersen Corporation
Federal Tax ID #41-1918413
104 Otis St., Northborough, MIA 01532
(508) 351-2200 • Fax: (651) 351-4810
CUSTOM WINDOW AND DOOR REMODELING AGREEMENT
Name
Date of
Buyer(s) Street Address, City, State, and Zip Code
E -Mail Address U Home Telephone Number Work Telephone Number
Buyer(s) hereby jointly and severally agrees to purchase the products and/or services of Renewal by Andersen Corporation
("Contractor"), in accordance with the terms and conditions described on the front and the reverse of this agreement and on the attached
specification sheet(s) (collectively, this "Agreement"). Buyer(s) hereby agrees to sign a completion certificate after Contractor has completed
all work under this Agreement.
Total Job Amount: ! N
Deposit Received (33%): 7 1 r�
� 9
Balance at Start of Job (33%):_Z_L-°=
Balance on Substantial -7' a' Da
Completion of Job (33%):
Estimated Starting Date:
/o lL
Estimated
Completion Date:
-J' v—GU
Method of Payment:
❑Check ❑Cash ,(Financed
❑Visa/MC ❑Discover ❑AMEX
If credit card is selected, please see Credit Card
Payment Form.
Buyer(s) agrees and understands that this Agreement constitutes the entire understanding between the parties, and that
there are no verbal understandings changing or modifying any of the terms of this Agreement. No alteration to or deviation
from this Agreement will be valid without the signed, written consent of both Buyer(s) and Contractor. Buyer(s) hereby
acknowledges that Buyer(s) 1) has read this Agreement, understands the terms of this Agreement, and has received a
completed, signed, and dated copy of this Agreement, including the two attached Notices of Cancellation, on the date first
written above and 2) was orally informed of Buyer's right to cancel this Agreement. DO NOT SIGN THIS CONTRACT IF
THERE ARE ANY BLANK SPACES.
Renewal by Andersen Corporation
By:
Signature of Produ Manager
Print Name of Product Manager
Buye Buyer(s)
�Ior
ure Signature
Print Na4 7—
Print Name
YOU, THE BUYER(S), 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 FORMS
FOR AN EXPLANATION OF THIS RIGHT.
�c — — — — — — — — — — — — — — —�,<- — — — — — — —
NOTICE OF CELLATION X
Date of Transaction 2. You may cancel
this transaction, without any penalty or obligation, within
three business days from the above date. If you cancel, any
property traded in, any payments made by you under the
Contract of Sale, and any negotiable instrument executed
by you will be returned within 10 days following receipt
by the Contractor ("Seller") of your cancellation notice,
and any security interest arising out of the transaction will
be canceled. If you cancel, you must make available to the
Seller at your residence, in substantially as good condition
as when received, any goods delivered to you under
this Contract or Sale; or you may, if you wish, comply
with the instructions of the Seller regarding the return '
shipment of the goods at the Seller's expense and risk. I
If, you do make the goods available to the Seller and the
Seller does not pick them up within 20 days of the date
of your Notice of Cancellation, you may retain or dispose
of the goods without any further obligation. If you fail to
make the goods available to the Seller, or if you agree
to return the goods to the Seller and fail to dso, then
you remain liable for performance of all obligations under I
the Contract. To cancel this transaction, mail or deliver a I
signed and dated copy of this cancellation notice or any I
other written notice, or send a telegram to Contractor.
Renewal by Andersen Corporation, 104 Otis
Street,Northborou n, 01532, BY NOT LATER THAN
MIDNIGHT OF Y , (Date)
1 HEREBY CANCEL MIS ilRANsAcnON.
- - - - - - -�<- - - - - - - - - - - - - - -x
NOTICE -9f NCELLATION
Date of Transaction r L You may cancel
this transaction, without any penalty or obligation, within
three business days from the above date. If you cancel, any
property traded in, any payments made by you under the
Contract of Sale, and any negotiable instrument executed
by you will be returned within 10 days following receipt
by the Contractor ("Seller") of your cancellation notice,
and any security interest arising out of the transaction will
be canceled. If you cancel, you must make available to the
Seller at your residence, in substantially as good condition
as when received, any goods delivered to you under this
Contract or Sale; or you may, if you wish, comply with the
instructions of the Seller regarding the return shipment of
the goods at the Seller's expense and risk. If you do make
the goods available to the Seller and the Seller does not
pick them up within 20 days of the date of your Notice
of Cancellation, you may retain or dispose of the goods
without any further obligation. If you fail to make the
goods available to the Seller, or if you agree to return the
goods to the Seller and fail to do so, thenYou remain liable
for performance of all obligations under the Contract.
To cancel this transaction, mail or deliver a signed and
dated copy of this cancellation notice or any other written
notice, or send a telegram to Contractor:
Renewal by Andersen Corporation, 104 Otis Street,
Northb ro hg� 01532, BY NOT LATER THAN MIDNIGHT
OF c . (Date)
I HEREBYCANCEL THIS TRANSACTION.
Buyer's Signature Print Name Date Buyer's Signature Print Name Date
RbA Copy - White Buyer Copy - Yellow Buyer Copy - Pink QBaP2009.RBA4Ph.MANH