31A-204 •
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• Rene I - _
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byAndersen. -� -
P ;s p "k WINDOW REPLACEMENT tnMdesaenCnmpinc '
Wood/ Vinyl Composite IF •
iAttpwFgaegVatak Dual Argon Low E4 SmnartSun
fir ar Double Hung
. '1NOMN 100-00473518-010
.ENERGY PERFORMANCE RATINGS •
U- Factor (U.S)/I -P Solar Heat Gain Coefficient 1
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0.29 0.19 •
• ADDITIONAL PERFORMANCE RATINGS
Visible Transmittance
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Manufacturer stipuYtss that there rating conform teapprrcahl. NFAC for datermrinp whole product
pedomance NPAC =dingo am datannined bra fixed oat of environmental nmnd'aionaand aapwYre product ado.
NFAC does ant recommend any product and doss not warrant the suirabnTsy of any product forany spooirc ma.
Consult manufacturer's rsarsture for other product p.dormanoe information.
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ems . affeieney, heavy matak ; 1� : • .'+� � y� -,f
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DESIGN PRESSURE (PSF) • WT MA
• • Wnmrr am thor n ERTIFIED
• RbA DB Sloped Sill DH IN .
Tested Off 2 fMM%OAAS4 7ptASIAMOdS LtYrfiadVQ otiouator conformance D TO apptt:she standards.
• Beats or exceeds MF'C. C.EC, & LE-C.C. Air Infiltration requirements WDMA fiavmank Canio.tion Program
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• • _ . • Wood/Vinyl GDt!dtu� . • _ ; _ _. • ' 2 1 1 b 14 PlI -- LOW E4 ding with Neon
- 152e544 't529544 — — — _ . •
• . . " • ENERGY PERFORMANCE, RATINGS .. • ' • , • • • -. : . . ;
' '...U-Factor (11 .S..). : far Hut Gatti merit • _ . , . .
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• • • . : " ADDITIONAL PERFORMANCE .RATINGS • ::, .
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. . Manufactu stipulates that these ratings cordon to applicable 'RC procedures For detentdning whole " •
product performance, iNRiC ratings. are detprrrttned for I rand set of environmental conditions and a -
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• specific product Ilne. Consult manufect rer's literature for other product performance information.
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• • . Meats or exceeds-M.E.C,. I:EC., & LEC.C. At IndlUadon Requirements,WLMA Hadrnark Cestitkarian Noggin •
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• • Massachusetts - Department of Public Safet}
• 7 Board of Building Regulations and Standard
Construction Supervisor License
License: CS 101952
. Restricted to 00 '
• r
DAVID BANCROFT
5 JOHNSTON AVENUE
' WHITINSVILLE, MA 01588 1
�� --9.-_,. Expiration: 3/19/2012
. ( 'oromisioner Tr#: 101952 u.
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• :fie -6omvrrwoeweala o' acAtusee&
Office: of Consumer Affairs & Business Regulation
'E� =E OMIE IMPROVEMENT CONTRACTOR
r =j_ r_ g R egistration 149601
\ J Expirahi =i`s ;;.: _? 12 .
n te it r Card -
RENEWAL BY PQ_ Qh
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�;�'
DAVE BANCROP
104 OTIS STREET ,'., .`—
• NORTHBOROUGH,'1til0 32 Undersecretary
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F
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ACORD CERTIFICATE OF LIABILITY INSURANCE DATEIMMRDD "YYY)
02/10/2010
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Joseph McKeone ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
JP McKeone Insurance Agency, IrIC. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 333
Ann Arbor, MI 48106 - 0333 INSURERS AFFORDING COVERAGE NAIC #
INSURED Renewal by Andersen INSURER k . Hartford insurance Company •
J and L Windows, Inc. INSURER B: Nautilus
1 04 Otis St INSURER C:
Northborough, MA 01532 INSURER D:
INSURER E:
COVERAGES
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADD'L POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR INRRD TYPF OF INSURANCE DATE ( M/OD/YY1 DATE IMM/OD/VYI
B GENERAL LIABILITY NC958461 10/01/2010 10/01/2011 EACH OCCURRENCE 5 1,000,000
X! COMMERCIAL GENERAL LIABILITY PREMS(RENTED
PREMI E SES (Ea omurencel $ 1 00,000
CLAIMS MADE OCCUR MED EXP (Any one person) $ 5,000_
• PERSONAL & ADV INJURY 5 1.000.000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG 5 2,000,0000
; POLICY LOC
A AUTOMOBILE LIABILITY 35MCC XD 6390 10/01/2010 10/01/2011 COMBINED SINGLE LIMIT S 1,000,000
ANY AUTO _ (Ea accldenl)
X ' ALL OWNED AUTOS
BODILY INJURY $
; SCHEDULED AUTOS (Per person)
I HIRED AUTOS BODILY INJURY.
NON -OWNED AUTOS - (Per accident)
1
PROPERTY DAMAGE
(Per accident)
GARAGE.LIABILITY •. •. AUTO ONLY - EA ACCIDENT $
• I ANY AUTO • r OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
- OCCUR CLAIMS MADE - AGGREGATE S
- DEDUCTIBLE _ S
i RETENTION $ $
A WORKERS COMPENSATION AND 35 WECPP 1444 02/17/2010 02/17/2011 TORY oars ER
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER.EXECUTNE EL EACH ACCIDENT $ 500,000
OFFICER/MEMBER EXCLUDED? EL DISEASE - EA EMPLOYEE $ 500,000 describe under
II SPEC AL PROVISIONS below EL DISEASE - POLICY LIMIT 5 500.000
OTHER •
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DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
•
CERTIFICATE HOLDER CANCELLATION
• SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
INSURED COPY • DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1 0 DAYS WRITTEN
NOTICE TO THE•CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DD SO SHALL
•
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
• REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE ny/ o
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ACORD 25 (2001/08) ® ACORD CORPORATION 1988
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. ,The Commonwealth of Massachusetts •
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- Department of Industrial Accidents -
==' t - f Office of Investigations .
I. _ ;,� Z 600 Washington Street
• r Boston, MA 02111
4
-��`, w1vw miss gov /dia •
Workers' Compensation durance Affidavit PuiIaers /Con raet€rrs/Elec iejans/PIumbers
Applicant Information Please Print Leeoly
Name (Business/organization/Individual): t en eU c,. I .. y ,9 e 11
,Address: . /0 6/ ti S &c=-7
City /State/Zip: I /0f h be ro AI o) 3.9__ Phone #: (- f) 7 0 9' OG • •
•
Are you an employer? Check the appropriate box. • - Type of project (required):
1.E am a employer with r3 a 4. ❑• I am a general contractor and I 6. ❑ New construction '
employees fail and/or part-time).* have hued the sub- contractors
� P ) "
2. ❑ I am a sole proprietor or partner- listed on the attached sheet $ 7: lir, : •. • deling
ship and have no employees . ' 'These sub - contractors. have . 8. • Demolition
worr for me in any capacity. • workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10 -I] Electrical repairs or additions
required.] • officers have exercised their
3. ❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp: c. 152, g1(4), and we have 33.0 ' 12 Roof repairs •
insurance required.] t • employees. [No workers' 13.❑ Other
comp. insurance required.]
`Any applicant that a in at chec s bo nwi`w,tt also fill out the section below showing their workzrs' compmsatiou policy n�oa oe. •
t I Homeowners who submit this affidavit iert,rat5n g they are doing all work and then hire outside matadors most submit anew affidavit indicating such.
tanitractors that check this box most attached an additional sheet showing the name of the sub-contractors and their wadrers' comp. policy information
I am an employer that is providing workers' compensation insurance for my emcplvyees. Below.is the policy and job site
information. . ) -
Insurance Company Name: 7- • ? A9 p. Ic•e_o n /fl Srifo n C C..
Policy # or Self-ins. Lin. 4 1 S / i Expira#ionDatE: , k.
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Job Site Aciriress :)(n 1,;) �t S . v f c:ci 4 v ieL City /5tate/Zip: ?V;? A- 1'1k �t 1 n( 1L c� i C ( o ��
.ttacli a copy of the workers' compensation policy declaration page (showing the policy n�eber an e xpiration d ate).
Failure to secure coverage as required ender Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the fog of a STOP WORK ORDER and a ale
•of up to $250.00 a day against the violator. Be advised that a copy of this stat -namnt may be Ioiwdided to the Office of .
Investigations of the DIA for insurance coverage verification.
I do hereby under the pains and penalt€espfperfury that the information provided above is true and correct
Sitrnature: Ce � ? i Date: 11 1 4/,-9 ir c
Phone #: / ' - .0 ) -6 co •
,
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• Official ;Is only. Do not write in this area, to be completed by city or town officiaL • •
City or Town: - Permit/Licerse # .
Issubg Authority (circle one):
• L Board of Health 2. Bixitr£ing Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #: .
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R enewal 4 ;����A., RENEWAL BY ANDERSEN MA License # 149601 #1491 Tax ID #
byAndersen• � OF GREATER MASSACHUSETTS AND NEW HAMPSI'kitt£
WINDOW REPLACEMENT .,, Andersen Company 104 Otis Street • Northborough, Massachusetts 01532
Phone 508.919.0900 • Fax 774.987.3013
CoNrsAcr MRENDMENT
This Amendment ( "Amendment") is to the CUSTOM WINDOW AND DOOR REMODELING AGREEMENT ( "Agreement") by and between J &L
Windows, Inc. dba Renewal by Andersen of Greater Massachusetts and New Hampshire and ANN MCEWEN ( "buyers"). Contractor and Buyer
(s) hereby agree to amend and modify the Agreement as indicated below. Other than as specifically indicated below, all the terms and conditions
of the Agreement will remain in full force and effect. This Amendment is subject to the terms and conditions of the Agreement. The following
additions, alterations, or deletions to the products and services Buyer(s) ordered are being made:
ADD (7) WINDOWS IN KITCHEN
(13) FREE GRIDS
TO EXISTING CONTRACT
$8102
As a result of these changes, the following terms of the Agreement are also changing (if there is no change, an item will be left blank or marked
as "N /A ", indicating that no change applies:
NEW Total Job Amount: $23000.00 New Estimated Method of J Cash V Check ❑ Mastercard
Starting Date: Payment:
New Deposit Received
(33 %): $7449.00 Finance
RECEIVED ❑ Visa ❑ Discover -/ Financed
New Balance at Start of Job
(33 %): N/A New Estimated
Completion Date: Name on Credit Card:
New Balance on Substantial Credit Card #:
Completion of Job (33 %): $11551.00 Finance
$4000.00 Customer
CC Exp. Date: CC Security Code:
By initialing here, you acknowledge that the Balance at Start of Job and the Balance on Substantial
Completion of Job cannot be made by credit card and must be made by personal check, bank check, or
Buyer Initials cash.
It is agreed and understood by and between the parties that this Amendment and the original Agreement constitute the entire understanding
between the parties, and there are no verbal understandings changing or modifying any of the terms of this Amendment. Buyer(s) hereby
acknowledges that Buyer(s) has read this Amendment and has received a completed, signed, and dated copy of this Amendment on the date
written below.
Renewal by Andersen of Greater MA and NH Buyer(s)
By: _ 10/26/2010
E : 10/26/2010 "10: 18:50 PM.CST
Signature of Product Manager Date
Ann McEwen
mcthomson @comcast
TOM WILSON IP: 71.192.24.49
nocr�aai a in zs rue
Print Name of Product Manager Signature Date
Doc ID: 20101025144857316
Sertlfl Electronic Signature
R enewal RENEWAL BY ANDERSEN MA HIC License # 149601 (expires 1/24/10)
Federal Tax ID# 83- 0404201
bYMdersen. O F L,..iATER M ASSACHUSETTS AND N EW H AMPSHr:,.,
WINDOW REPLACEMENT .Aodeen Camps,
104 Otis Street • Northborough, Massachusetts 01532
Phone 508.919.0900 • Fax 508.919.0903
SPECIFICATION SHEET
Buyer(s) Name Date of Agreement
J ve,n
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 1 ( windows in Owner's home, using the following individual quantities:
to Double Hung (DB) Ail 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 El 1:2:1 ❑ Standard handle ❑ Metro handle
2 Lite Gliding Window (GW)
Glider / Picture / Glider (GPW) ❑ 1:1:1 or ❑ 1:2:1
Awning Window (AW)
Picture Window (PW)
Bay or Bow Window
Patio Doors (see separate Door Specification Sheet)
2. Yes ❑ No Qty of Windows to be Custom Fit Replacement: l
3. ❑ Yes o Qty of Sills to be replaced by Contractor:
4. ❑ Yes No Qty of Windows to be New Construction Full frame (includes new interior & exterior casings)
Exterior casings: ❑ Pine ❑ Maintenance -free material ❑ Factory applied 908 Fibrex brickmold
5. Glazing to be: HP Low -E® SmartSunmr (Tax C editE.ligible) El Other If other, please specify:
6. Exterior color to be: 0 White ❑ Sand ❑ Canvas ❑ Terratone ❑ Cocoa Bean
7. Interior color to be: 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: in White El Stone ❑ Canvas ❑ Brass Double Hung:
9. ❑ Yes RI No Install Lifts th Double Hung Windows
10. Screens: windows to have: Half or a Full screens Screens to be: g Fiberglass ❑ Aluminum ❑ TruScene
GRILLE DETAILS
1 1. Windows have grilles: WYes ❑ No If yes: ❑ Grille Between Glass (GSG) IN Removable Interior Wood (1NFW) ❑ Full Divided Light (FDL)
QV: ____3___. QtY: Qty: Qty: QtY: QtY: Qty:
DH DH DH DH CW /Picture Glider CPW or GPW
Draw grille patterns above 'Use additional sheet if needed Owner approved (inifials): ( )
ADDITIONAL WORK DETAILS
12. ❑ Yes g Contractor will remove metal frames of windows. Qty of Units:
13. ❑ Yes 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 V. No Contractor will install new paint -ready or stain -ready inside or outside stops qty of openings:
Interior stops qty of openings: Exterior stops qty of openings: ❑ Pine ❑ Maintenance -free material
15. Owner is aware that Contractor does not do any painting. ( ) Owner Initials
16. ❑ Yes No Contractor will wrap exterior casings with aluminum coil stock of color.
Note: Wrapping may be required with storm window removal; removal of storm windows will leave screw holes in casing.
17. Z- Yes ❑ No Contractor will insulate, caulk and seal windows with 3 -point system to prevent water and air infiltration.
18.-S1_ Yes ❑ No A limited warranty shall be issued to Owner upon completion of the job and payment in full.
19. gYes ❑ No Building Permit —Contractor will secure any and all necessary permits. The fee for the permit(s) is not
included in the Contract Price and a sep ate chec required at the time sale for this fee.
Addi 'onal job details: f` j r . J n T W
20 ai i h �f'a+, , / /��L st vL a 1 r� FYI / P,47._ _ 5, we 4.. Tx 3 6rol
21. .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.
Renewal by Andersen reater MA and NH Buyer( ��, Buyer(s)
•
. A.
Signature of Product Manager Signature Signature
fo- I .`j ISOA
Print Name of Product Manager Print Name Print Name
RbA Copy - White Customer Copy - Yellow
Renewal P l , BY ANDERSEI MA HIC License #149601 (expires 1/24 /10)
Federal Tax ID# 83- 0404201
Andersen.
WINDOW REPLACEMENT anAndersenCm, OF GREATER MASSACHUSETTS AND NEW HAMPSHIRE
104 Otis Street • Northborough, MA 01532
Phone 508.919.0900 • Fax 508.919.0903
CUSTOM WINDOW AND DOOR REMODELING AGREEMENT
Buyer(s) Name Date of Agreement
l
4 Ji „ ► A4( f= w /6 —,2 N ra
3uyer(s) Street Address, City, State, and Zip Code
lit 5 t VI- )71" u /l /�� . �,- X70 ,, /1 o k) 6�
E-Mail Address Home Telephone Number Work Telephone Number
0 1 3)sfo — 9 (Lt
Buyer(s) hereby jointly and severally agrees to purchase the products and /or services of J & L Windows, Inc. dba Renewal by Andersen of Greater
Massachusetts and New Hampshire ( "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.
1 Q Method of Pymnt: D Cash 0 Check ❑ Mastercard D VISA
Total Job Amount:_1 l r Estimated Starting Date:
1 - Discover Cinanced, App #:
Deposit Received (33 %) :_ (f Name on Credit Card:
Balance at Start of Job (33%): — Estimated Completion Date: Credit Card #:
Balance on Substantial !' �rj( S
Completion of Job (33 %): CC Exp. Date: CC Security Code:
By initialing here, you acknowledge that the Balance at Start of Job and the Balance on Substantial Completion
Buyer Initials of Job cannot be made by credit card and must be made by personal check, bank check, or cash.
Buyer(s) agrees and understands that this Agreement constitutes the entire understanding between the parties, and that
:here 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
['HERE ARE ANY BLANK SPACES.
Renewal by byAn of Greater MA and NH Buyer(s) Buyer(s)
3y: — ✓` �, il ■1 `.. '1 i
Signature of Product Manager Signature Signature
Print Name of Product Manager Print Name Print Name
fOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD
3USINESS DAY AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FORMS
FOR AN EXPLANATION OF THIS RIGHT.
NOTICE OF CANCELLATION X NOTICE OF CANCELLATION
)ate of Transaction to — . You may cancel Date of Transaction a — l d . You may cancel
his transaction, without any penalty or obligation, within I this transaction, witho6t any penalty or obligation, within
hree business days from the above date. If you cancel, any three business days from the above date. If you cancel, any
toperty traded in, any payments made by you under the I property traded in, any payments made by you under the
:ontract of Sale, and any negotiable instrument executed I Contract of Sale, and any negotiable instrument executed
ty you will be returned within 10 days following receipt I by you will be returned within 10 days following receipt
ty the Seller of your cancellation notice, and any security by the Seller of your cancellation notice, and any security
nterest arising out of the transaction will be canceled. I interest arising out of the transaction will be canceled.
f you cancel, you must make available to the Seller at If you cancel, you must make available to the Seller at
'our residence, in substantially as good condition as your residence, in substantially as good condition as
Alen received, any goods delivered to you under this I when received, any goods delivered to you under this
:ontract or Sale; or you may, if you wish, comply with the I Contract or Sale; or you may, if you wish, comply with the
istructions of the Seller regarding the return shipment of instructions of the Seller regarding the return shipment of
he goods at the Seller's expense and risk. If you do make X the goods at the Seller's expense and risk. If you do make
ie goods available to the Seller and the Seller does not the goods available to the Seller and the Seller does not
pick them up within 20 days of the date of your Notice pick them up within 20 days of the date of your Notice
f Cancellation, you may retain or dispose of the goods of Cancellation, you may retain or dispose of the goods
+ithout any further obligation. If you fail to make the I without any further obligation. If you fail to make the
oods available to the Seller, or if you agree to return the I goods available to the Seller, or if you agree to return the
oods to the Seller and fail to do so, then you remain liable goods to the Seller and fail to do so, then you remain liable
r performance of all obligations under the Contract. for performance of all obligations under the Contract.
cancel this transaction, mail or deliver a signed and I To cancel this transaction, mail or deliver a signed and
ated copy of this cancellation notice or any other written dated copy of this cancellation notice or any other written
otice, or send a telegram to Renewal by Andersen I notice, or send a telegram to Renewal by Andersen
f Greater Massachusetts and New Hampshire, 104 I of Greater Massachusetts and New Hampshire, 104
Itis Street, Northborough, MA 01532, NOT LATER THAN Otis Street, Northborough, MA 01532, NOT LATER THAN
IIDNIGHT OF 11�� —1 B . (Date) MIDNIGHT OF d - Zy-/ . (Date)
HEREBY CANCEL THIS TRANSACTION. X I HEREBY CANCEL THIS TRANSACTION.
msumer's Signature Date i Consumer's Signature Date
RbA Copy - White Customer Copy - Yellow Customer Copy - Pink
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size 1 I I
Frontage
I I I I
Setbacks Front
' Side 1.,:i R L: R:= F .1
Rear I € = E
Building Height ' i
Bldg. Square Footage = I % 1 I j I
Open Space Footage I % � = jj —'`�
(Lot area minus bld g & & paved L�
parking)
# of Parking Spaces
Fill: _ 0 . _ _,.
(volume & Location)
.i
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW 0 YES . 0
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW ip YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location: 1
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO
IF YES, describe size, type and location: i
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : ! ■,■ c 6 fi V'AC
License Number
fit: � \� ? 5 �, 3 -I t a
�O�vv�yl Jc \��V` r
Address Expiration Date
ignature Telephone
§:' 3e ,s ®r tWalre i : onliradfor ,__ a Z µ . S trcomuzi Not Applicable ❑
Q ar.. J \pi c)ne_, �z� � C iLz.
Company Name Registration Number
Address Expiration Date
ti
• Telephone t 3R' c •(l
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes No ❑
• 1�1 fi om O x emnta o n
The curre - emption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families
and to allow suc • • eowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 7: i, 'xth Edition Section 108.3.5.1.
Definition of Homeowner: Per . s) who own a parcel of land on which he /she resides or intends to reside, on which there
is, or is intended to be, a one or two f. dwelling, attached or detached structures accessory to such use and/ or farm
structures. A person who constructs more t ,ne home in a two -year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Of 1 ' : on a form acceptable to the Building Official, that he/she shall be
responsible for all such work performed under the buil • • • ermit.
As acting Construction Supervisor your presence on the job site I be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation :Id Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws • otated, you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the : e Building Code, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws • otated.
Homeowner Signature
SECTION 5- DECRIPTION OF PROPOSED WORK (check all applicable)
New I-louse ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing El
Or Doors A.
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [❑ Siding RD] Other ED]
Brief Deription of Proposed
Work: V.0 p\ e \1� W tiv� � � S te, r yr \ Vt�cY�� L
Alteration of existing bedroom Yes 1( No Adding new bedroom Yes - No
Attached Narrative Renovating unfinished basement Yes ( No
Plans Attached Roll - Sheet
sa" N w: ouse`and o r a elition.to' houstnq "c omple a the.follow ng:
a. Use of building : One Family V Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance: Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a OWNER AUTHORIZATION - TO. BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, rxt Y vle , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, � c. n C f ctfyT . , as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best 6fTf59 now e -
and belief.
i ned under the pains and penalties of perjury.
Print Name
4„; SS" c (2..9)
ignature of Owner /Agent - -___- Date
A# .. GTON AVE ` BP-2011-0496
GIS #: COMMONWEALTH OF MASSACHUSETTS
IED k: 31A - 204 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2011 -0496
Protect # JS- 2011- 000811
Est. Cost: $23000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RENEWAL BY ANDERSEN_
Lot Size(sq. ft.): 11238.48 Owner: MCEWEN ANN L & DAVID THOMSON
Zoning: URB(100)/ Applicant: RENEWAL BY ANDERSEN
AT: 26 WASHINGTON AVE
Applicant Address: Phone: Insurance:
104 OTIS ST (508) 919 - 0900 WC
NORTHBOROMA01532 ISSUED ON:11/29/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House # Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 11/29/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner