16A-020-041 BP-2023-0202
311 FAIRWAY VILLAGE COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
16A-020-041 CITY OF NORTHAMPTON
Permit: Exterior Res
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit # BP-2023-0202 PERMISSION IS HEREBY GRANTED TO:
Project# WINDOWS 2023 Contractor: License:
Est. Cost: 23864 RENEWAL BY ANDERSEN 090125
Const.Class: Exp.Date: 10/06/2024
Use Group: Owner: TRUSTEE PARSONS ELAINE RUTH
Lot Size (sq.ft.)
Zoning: URA Applicant: RENEWAL BY ANDERSEN
Applicant Address Phone: Insurance:
30 FORBES RD 508-351-227 MWC31415822
NORTHBOROUGH, MA 01532
ISSUED ON: 02/22/2023
TO PERFORM THE FOLLOWING WORK:
INSTALL 5 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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
11
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
Department use only
R�_—c"�t- City of Northampton Status of Permit:
t �-= --�� Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
FEB al b 2023 Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
,,.* CIF miii r",
phone 413 587 1240 Fax 413 587 1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:1 1 /�Map /0 0 Lot 63° Unit
`7'"' ' 1/ `c Guy Ili
I I I Q0-E_____ Zone Overlay District
(.._ells , Ant,)0 S3
Elm St. District CB District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
5 1 a(Nc_ 'Pars�•-\.s y: . SgPrr S 1?---, ttw M
,� 3/1 Leeds A
Name(P int) Current Mailin rc Addres 0i /US-3
671/Y / Telephone
Signs ure
2.2 Authorized Agent: �I
6e fx. l c✓ � . C �_ �1�-- /d"j ,[�if t #4 h 4,C,40- (J 44101211
J✓' 4-'') C r
Name(Pr Current Mailing Address: c(O S3
Signs re Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 23 ea c/ (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee •`
4rill)
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 +2 + 3 +4 + 5) 2_3 36 t/ Check Number NCO/ 7
This Section For Official Use Only
bl- A 3 - Na Date
Building Permit Number: Issued:
Signature: YAv! - 97 ,3
Building Commissioner/Inspector of Buildings Date
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Whro)Oclivs Alteration(s) j Roofing p
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding [DI Other[0]
Brief Description of Proposedv /
Work: fYl� Ctv►�c! K2�fc fG Sr'�►�✓i n ..v, // � // vl/iA ,7 o S 4 GhR S.
uF0.chi- se . 30 .
Alteration of existing bedroom Yes 4--"--No Adding new bedroom Yes 1�No
Attached Narrative Renovating unfinished basement Yes 1-/-No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building: One Family 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, tit-A , kt, POk 'S0AS , as Owner of the subject
property danCZ),)
hereb authorize / F14 4 to a m beh , •n a afters relative work a orized by this building permit application.
Sign ure o n Date 2— r .— Z 3
I, tQ t (4/ti C • £ AO)' O/L , as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
n, ( CI C.. Cr- v c,-
Print a
4A1/
1 � 2 . �s_z3
Sign re of er / Date
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Jo-i Nte_ /110r%4 090 /Z$
• Y gd £vv//7 bb� / . /"G License Number
Addresj Expiration Date
- 95-7 - Yl l7
Si'.ttture V Telephone
9. Registered Home Improvement Contractor: Not Applicable 0
gero-vd 4-r icM O tt) / 8/0
Company Name Registration Number
Address
,11 Expiration Date
Telephone .0 -95-2- CM
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 0
11. - Home Owner Exemption
The current exemption for`homeowners"was extended to include Owner-occupied Dw ellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person(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 family dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner'shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall he
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will 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) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifi and assumes responsibility for compliance with the State Building C' e,City of
Northampton Ordinances,State and 1 Zo ws and State of Ma tts General Laws Annotated
Homeowner Signature •
The Commonwealth of Massachusetts
Department of Industrial Accidents
' t Office of investigations
�� Lafayette City Center
�'r— 2_Avenue de Lafayette. Boston,MA 02111-1750
1 www.mass.Rov/dia
Workers"Compensation Insurance Affidavit: Builders.
Applicant Information Please Print Legibly
Renewal by Andersen
Name 1 Business nmanication Individual):
Address: 30 Forbes Rd.
City/State Zip:Northborough, MA 01532 Phone#:508-351-2277
Are you an employer:'('heck the appropriate box: -hype of project(required):
I_X I am a employe! w tth 30 4. ❑ I am a general contractor and I
employees(full and,+or time)." lave hired the sub-contractors b. New construction
2.❑ I am a sok proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have S. 0 Demolition
workingfor me in any capacity. employees and have workers"
y P ty 9. 0 Building addition
[No workers" comp.insurance comp. insurance.:
required.) 5. [] We are a corporation and its io.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. No workers' comp. right of exemption per MGL
12.0 Roof repair,
insurance required.] a c. 152.§1(4),and we have no Re placement
employees. [No workers' 13 (ltler P
comp. insurance tequued.]
*Ate}apphcaZii that cheeks box=I must also till out the section hely% shooing Men ire kas*compensation ply information.
Ilt>rncualla+o hl/submit this a1Txt:tl it IaiL-atutl'the.%Ate dump.all Mtuk atld then lute outside cti l 1uts mist submit a new atlitho it itldicating such.
't omit:taut,Ill:et a heck this loon must attatc'lied ate aitdltilnial sheet slll,N u11 the mime of the suh-ct*ittactots:mil l state Ntictha tit txtt th t se CCII11it.halt'
nupk.tet!. h the sub—tnittacelns lLlle eii ll.tces.ehet ntus-t pt tit lde iheu it.iltdcl. contr.pubes number.
I am an employer that is pro►vding rtorbers'compensation insurance for m► employees. Below is the policy and job site
information.
Insurance Company Name: Old Republic Insurance Co. 1
Policy#or Self-ins. Laic_#: MWC 314158 22 Expiration Date:10101/2023
Job Site Address: XX 9STC sr1/`"� St s f %0 ('ttv;Stale tip XX � �/1/1- 0 /0 3
Attach a copy of the aerkcrs'es Wt ipeasation peiit'y declaration page(shots ing the polk number and expiration date).
Failure to secure coverage as required under Section 25A of MtiL c. 152 can lead to the wiposition of criminal penalties of a
tine up to Si.500.00 and or one-year imprisonment. as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to S250.00 a day against the violator_ Be ads vied that a copy of this statement may be forwarded to the Office of
Investigations of the I)1A for insurance coverage verification.
I du hereby certify under the pains and penalties of perjury'that the information provided above is true and correct.
Silm.lttirr /1 P'24IL u.,t, XX 2 -/3----- Zj
1'1),.. :.. :08 - )5 I - 2 Z q-
Official use only. Do not write in this area.to he completed hr city or town official
City or I awn: Pernut l.kense is
Issuing %uthority(check one):
10 Board of I leahh 20 Building Department 30('ity!1 ow n(Jerk 4.0 Electrical Inspector 5/Plumbing
Inspector 6.❑0ther
Contact Person: Phase is:
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: '/SS 5 (tirce 3 eds.) nil- 0 I0S
The debris will be transported by: ge/lpv✓(-t4 4 ble/rsoli
The debris will be received by: &U
Building permit number:
Name of Permit Applicant tft(c/ t C/a, al/r
2- 4-LW
Date Signature of Permit Applicant
Go Permits, LLC
ellOM 105 Buttonball Lane
Glastonbury, CT 06033
. PERMITS Scott Doughman
\,,,,,,,,,,,,Nima,0001 Phone: 860-952-4112
Fax: 860-430-6719
scottdoughman@gopermits.org
Re: Building Permit Application - Licenses
Good day.
Please find attached permit application, licenses and supporting documents.
Renewal by Andersen sold the job and is the G.C. and CSL
- CSL #CS-090125 -- Exp. 10/06/24
- HIC #170810 -- Exp 12/22/23
- Workers Comp -#MWC 3145822 — Exp. 10/01/23
Old Republic Insurance Co
All licenses and insurances are attached.
Once the permit is ready:
• Please fax or e-mail a copy of the permit and receipt to the below address and mail
the original to the homeowner:
Fax: 860-430-6719
Email: renewalbyandersen( gopermits.orq
• If you unable to mail the permit to the homeowner please send to the below address
and we will ensure the permit is at the home posted at the time of installation:
Go Permits, LLC
105 Buttonball Lane
Glastonbury, CT 06033
If we are required to pick up the permit in at the building department, please call 860-952-
4112 once it's ready and we will come to get it.
Thank you,
Go Permits
,a!'-!- ♦ Paste 1 of I
/•Nl_l JROO DATE AITATIONTY1'
CERTIFICATE OF LIABILITY INSURANCE 09/21/2022
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 OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING NSURER(S). AUTHORIZED
REPRESENTATIVE OR PRODUCER.AND THE CERTIFICATE HOLDER.
IMPORTANT: E the cuAMlear holds.'Is an ADDITIONAL INSURED.Om polley(M\)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED.subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder In lieu of such endorsement(s).
PROOUCEN CONTACT K111Ls Towers NAtfon Cos t1llcate Cor.[ea
Wallas Tow.• weans Mad...e. Inc. FAX
c/o 26 C.nLucy blvd ,A Eu.cr.. 1-a77-81S-737a Bw 1-1811-467-237s
P.O. loa 305191 Anne A, artt icntealtrillin-con
M..kvi11., TM 372305191 USA INSUREI SIAFFOID\N COVERAGE NOM
NNREIA. Old asptallLc Insurance COOpaay 1111W7
M0UIE0 INSURER\.
N.mmal by Anderson 11C
30 fort.. Road NNRERC.
NoctAbocoosb, MA 01532 NNANERO.
INSURER E
_NMI00R F.
COVERAGES CERTIFICATE NUMBER:11260076Si REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
on TYPE OEIIRIRANCE .J POLCY NIIANEI POUCBYYTYI rYYYL Lima
x co sus GERM/usaaiyY EACH OCC'IRIENCE s 2,000,000
OUTAG ID PENTED
CLAIMS-&BALELi OCCUR PREMISES oaunenc*j S S00,000
A LED EMT,;Any antWm^1 $ 10.000
F—.
IMft 314161 22 10/01/2022 10/01/2023 psRsoJNALawv MAIRY s 2.000,000
GENL AGGREGATE LSAT APPLES PER GENERAL M3OIEGATE s 4,000,000
PCUCY Q PRAT a LOC I PRODUCTS-CON40P AGO s A.000,000
OTHER
AUTOYORLE LIAaa1TY COMINIERD SINGLE UNIT s S,000,000
X ANY AUTO BOORY INJURY a+.^m s
A 0SCSIEDULED saris 314113 22 10/01F2C22 10?a1f2013 \couYmuuRY ref aNgasolfi
�.�MED AUTOSONLY AUTOS
NOISOMPED PROPERTY OgMAE
AUTOS ONLY AUTOS ONLY NNINNO
I
USWIRELLALW OCCUR ; EJACHOCCtO I
~_EXCESS LIMB a—aiat E AGGREGATE s
CEO I I NETantdts 1 1
WORKERS COMPENSATION P CT
AND EMPLOYERS'UM/MTVUM/MTVX 15(5ER 1015 I I ERH-
YI
A PA C».•-:rk:i ir;FLPARiHERE31c3TNE N EI EACH ACCIDENT S 1.000,000
6FFx_fkt3Eu6EREAOLUDED7 NIA WIC 3141511 22 10/01/2022 10/01/2023
INa.daiont \ry El.DISEASE-EA BREW YEE S 1.00'0,000
It yes orr.ce ands
DESCRIPTION OF OPERATIONS Oelm E L DISEASE-POLICY LINT I 1,000,000
DESCRIPTION OF OPERATIONS,LOCATIOrf YB\CLEO(ALA 1N,AsaI.AM I1ssMAs adhselAa,aay 6.aaa1Asa Paws soma Y atNrsall
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE NRTN THE POLICY PROVISIONS
AUTHOROEDREPNESENT1ATNE
Evidence of Insurance ^1,...!�
1988-2016 ACORD CORPORATION All rights reserved_
ACORD25(2016103) The ACORD name and logo are registered marks of ACORD
Commonwealth of Massachusetts CpIMMICfitlt fleparalsor
illf Division of Occupational Licensure Unrestricted-Buildings of sag we group whidi
Board of Building Regulations and Standards less than 35,000 cubic helm,fait owlets)o
Const( ItA'SUpervisor *Pam
CS-090125 , Expires: 10/0612024
JAIME L MOI3IN
54 NOTTINGM AM 1
RAYMOND NM >
e ' w
li•artvaf►') r:
Failure So possess a mood odds,of**
Cott:urizioncr (1 f ti+ i:1 , ado w/iitp Cods is Cant for revocable rlr�
,,ice ]7' For udorlrtattion about this fi.U
v Cal(117)TZ7-3200 or visit www
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
. -s Type Supplement Gard
�.�..�1. itegf5ttat oil, 170810
RENEWAL BY ANDERSEN LLC _ txprtatron 1Y1222021
30 FORB RD
N01TH8OROUGH MA 01532 w,
Update Addnres and Return Card.
THE COMMONWEALTH OF MASSACHUSEI1
R
Office of Gonsurner Affairs 6 Buagsneae Regulation Registration valid for individual use onty before Ina
HOME IMPROVEMENT CONTRACTOR aid ali"^'rags"' II found return to:
Office of Consumer Affairs and Business Regulation
TYPE;Supplement C 1000 Washington Street -suite 710
Ral170610 2f22/2tsil Boston,MA 02118
1T0010 1222t�bZv
Ri-"tFWAL By ANDERSEN tiC
JAIME MORIN
tit FORBES RD ,,,‘,,,,,...re r ,,.•r,..+, / C_.
typftTHBORCIIX+H,MA �71532 Not Iid without signature
tJndersesretary
�� RENEWAL
brANDERSEN
To 'Nhom It May Concern:
This letter will authorize the following personIs) to act as agent(s) on behalf of Renewal
Andersen LIC, 9900 Jamaica Ave South, Cottage Grove MN 55016 to pull for permits and
Inspections with respect to the installation, maintenance and repair of windows and entry
dnnrc under Massachusetts State Home Improvement Contractor license number 170810 and
Construction Supervisor License number CS-090125.
If you have any questions, please call me at 508.351.2277 ext 6.
Authorized persons f:
Go Permits LLC Sarah Hammact David Anderson Maureen Kivel
Scott Doughman Ryan Biondo Sovannara Kuy Mark Foster
Glynn Norgan iennifer Wtnke Wendy Hoiden Gerald Cramer
Nick Rago Dane(Vi kerman Stephen Wilder Katie Grocott
Bonnie Myers Carrie Folsgno Michael Rogers Rachel Orloff
;/arms Morin
Renewal by Andersen LLC
HIC 170810
CSI-CS090125
Local District Office Address
30 Forbes Rd
Northborough, MA 01532
• 99CO bmaw Ave south.Cottage Grave Mk 5501l;
y �� Agreement Document and Payment Terms
I—!
' DBA:RENEWAL BY ANDERSEN OF BOSTON Elaine Parsons
RENEWAL Legal Name:Renewal by Andersen LLC 455 Spring Stteet,Unit 311
HIC#170810 Leeds,MA 01953
brANDERSEN 30 Forbes Road I Northborough,MA 01532 H:(413)586-7870
Phone:(508)351-2200 I Fax:(508)986-7072 I rbaboston@gmaii.corr
Elaine Parsons 02/07/23 '
BUYERS)NAME CONTRACT DATE
455 Spring Street,Unit 311, Leeds,MA 01053 (413)586-7370
BUYER(S)STREET ADDRESS PRIMARY NUMBER SECONDARY NUMBER
dande311@comcast.net
PRIMARY EMAIL SECONDARY EMAIL
NOTES: Ham-shire Properties Management John McGee 413-582-9970
Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of Renewal by Andersen LLC d/b/a Renewal By Andersen of
Boston("Contractor"),in accordance with the terms and conditions described in this Agreement Document and Payment Terms,any documents listed in
the Table of Contents,and any other document attached to this Agreement Document,the terms of which are all agreed to by the parties and
incorporated herein by reference(collectively,this"Agreement").Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed
all work under this Agreement.
TOTAL JOB AMOUNT: $23,864 By signing this Agreement,you acknowledge that the Balance Due,and the Amount Financed
must be made by personal check,bank check,credit card,or cash.
DEPOSIT RECEIVED: $0
BALANCE DUE: $23,864 Estimated Start: Estimated Completion:
20 weeks 2-3 days
AMOUNT FINANCED: $23,864
We schedule installations based on the date of the signed contract and secondarily on the date
METHOD OF PAYMENT: Financing in which we complete the technical measurements.The installation date that we are providing at
this time is only an estimate.We will communicate an official date and time at a later date. Rain
and extreme weather are the most common causes for delay.
NOTES: 18 months-no money down; no payments; no interest if paid in 18 months.
Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are nO verbal
understandings changing or modifying any of the terms of this Agreement. No alterations to or deviations from this Agreement will be valid without the
signed,written consent of both the 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.
NOTICE TO BUYER: Do not sign this contract if blank.You are entitled to a copy of the contract at the time you sign.
YOU,THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 02/10/2023 OR THE THIRD
BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER. SEE THE ATTACHED NOTICE OF
CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT.
ANIf: (�l :All,
SIGNATURE OF SALES PERSON SIGNATURE SIGNATURE
Jim Scesny Elaine Parsons
PRINT NAME OF SALES PERSON PRINT NAME PRINT NAME
02/07/23 Page 2/27