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HomeMy WebLinkAboutBuilding Permit #032-13 - 131 DUNCAN DRIVE 7/17/2012 BUILDING PERMIT NoRrH Of,t`'eo bq~O TOWN OF NORTH ANDOVER �r h ''- �- °� APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received V � "OPQ y � � �'�SsgrED f' Date Issued: IMPORTANT:Applicant must complete all items on this page `LOCATIONS . ' tPnnt r PROPERTY OWNER'- � urs S MAP'NO: PARCEL 1R5 ZONINGiDISTRICT _ ,Histone District: ye's no, "`Machine ShogVillage' wyesl rno,1 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial epair, rep acem�n—� Assessory Bldg Others: DemolitionOther n Floodplain 'Wafershedbi Andt" Septic Well Water/Sewer— DESCRIPTION OF WORK TO BE PREFORMED: k+a' J cu' CL' w tip 04 r 7 Identification Please Type or Print Clearly) _ OWNER: Name: Phone: Address: ,.. � h $CO 'gC aPJPhoneAT2 - - Adcicess: _ Exp; ®ate= 2 - Z-�'( 'r l `� • , Su - 'bL*icense: ` t�f:_Q - Home Improvement License �.Lf-_I ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ `-7-ky 0 FEE: $ ) 4� .YD Check No.: 4 I I q Receipt No.: 2�6�1 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of A'_' _AOwn Signature of contractor, ' Location 1')V 3 C kt)6 No. O=72 Date Z • - TOWN OF NORTH ANDOVER • Certificate of Occupancy $ .� Building/Frame Permit Fee $ PX Foundation Permit Fee $ � Other Permit Fee $ t TOTAL $ Check 44-4ft 25509 Build' g 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 COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes R - Planning Board Decision: Comments I - Conservation Decision: Comments Water & Sewer Connection/Signature&Date- Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT =TempiDump'ster en site r yes . ja o �,.�, F� ` gat '-94IMain':Street Fire.'Department'signatureldate ._ COIVIMENTS - Dimension 11 Number of Stories: Total square feet of floor area, based on Exterior dimensions. I, 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 NOTES and DATA— (For department use �M 1N ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 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 Sprinkler Plan And ❑ Floor/Crossectlon/Elevation Plan Of Proposed Work With S p 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:INSPECTIONAL SERVICES DEPARTMENTMFORM07 Revised 2.2008 NORTH Town o E : 1, s ndover No. �O LAK! h ver, Ma 03 ;� 9q5_ COC KIC Kl MACK y1. A0 ATED S t] ti BOARD OF HEALTH R LD Food/Kitchen PE . Septic System ... Vii . THIS CERTIFIES THAT BUILDING INSPECTOR Foundation �, ... buildings on .�...1>W001io has permission to erect ....................... .... ...... .... .................. . .. � �. .. ... ... .. .� ..I Rough to be occupied as ....� .. ...... Chimney provided that the person acceptin tRis permit shall in a res ect conform to the terms of the a lication g p p pp Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR \� VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO TARTS Rough Service ............ oe ... r°°°"' ............................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE RooLing & Contracting Office 781-925-9596/Mobile 781-267-0253 Fax 781-925-9597 Po Box 43 Hull, Ma 02045 Job Location: 131 Duncan Rd North Andover, Ma Price: $12,000 Payment Schedule: 1/3 DOWN(deposit) 1/3 HALFWAY POINT 1/3 UPON COMPLETION Siding Remove siding from front and back sections of house, 13sq Install Tyvec house wrap. Install primed red cedar clap boards with step flashing at all seams. Fasteners will be stainless steel. Exposure will be 4" CONTRACTOR X �- DATE: ( 3 HOME OWNER X DATE: 91te � Office of Consumer Affairs and Business Regulation CIt 10 Park Plaza - Suite 5170 2 Boston Massachusetts 02116 V) '0 QN X N Home Improvement Contractor Registration .2 Zu W -0Cn Registration: 140993 Type: Individual ° - ��z�au''N r Expiration: 12/17/2013 Tr# 219072 m �� — fit f MICHAEL J. VIOLA (,� ";� ;, 3 L o y MICHAEL VIOLAI{ �7 -=- -i Q 0 .3. 4= - 8 HADASSAH WAY HULL MA 02045 Update Address and return card.Mark reason for change. = m C "� d%� o 1 Address 0 Renewal E] Employment t] Lost Card M o L J w Ln v DPS-CA1 Co 50M-04/04-G101216 N '0 a ( � - -- R MTie 0 �1 `r _ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: — Registration:, 140993 Type: Office of Consumer Affairs and Business Regulation Expiration: :12/17/2013 Individual 10 Park Plaza-Suite 5170 Boston,MA 02116 , MICHAEL J. MICHAEL VIOLA 8 HADASSAH WAY,--, HULL,MA 02045 Undersecretary Not valid without signature CERTIFICATE OF LIABILITY INSURANCE DAA("ftv"05/14/2012 ' 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 OR ALTER THE COVERAGE AFFORDED BY THE POLICIES MOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORISED 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, Sub to the tens and conditions of the policy, certain Policies may require an endorsement. A statement on this cartificats does n confer rights to the certificate holder In lieu of such eadorsement(a). PROOOCCR CONTACT John P Bergonzi VAX dba John P Bergonzi Inc Agcy (A//C. No. Eat) (A/C. No)S 75 F Street ADDRESS: PRO➢GCYR Hull, MA 02045 CUSTOM tori. INSUREDS) ATFORDING COVERAGE "At INSURED SHaORBk AS A.I.M. Mutual InSurance Cc 337 Michael Viola IHSORSA D: dba Viola Contracting INSURER CS :HullP O Box 43 INSURER D.- Hull, , MA 02045 INSURER ES INSURER FS COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THIS POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DocummT 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 TZ10-M. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SH- MAY HMAY HAVE BEEN REDUCED BY PAID CLAIMS. Ina POLICY NUMBER POLICY EFF POLICY EXP LIMITS Ltt TYPE OF INSURANCE 0w/MvwM ( / GENERAL LIABILITY EACH OOCURAM f 000)VERCIAL GENERAL LIABILITY DAMAGE TO RBH1'BD PRRitSEB(Se.oeourrenoa) 13AD 0cLPJVS RE ❑OCCUR NED ETP (Any ens person) S Y PSRSONAL t AOV INJOR ❑ S GEN'L AGGREGATE LIMIT APPLIES ERS GENERALGENERAL AGGREGATE LIO POLICY OPROJECT aWC PRODUCTS-CORP/OP AGO C e AUTOMOBILE LIABILITY COMINEO SINGLE LIHIT (fe Aeeldent{ Q QANY AUTO BODILY INJURY (pet pestsn) Q EIALL ODIED AUTOS 1:15CHEWLED AJTOS BODILY IRJURY(per souldtnt) S HIRED AVTOS PROPERTY DAMAGE i Ipee.eeld.Ml nNON-CWHED AUTOS Q VHSRELLA LIAR OCCUR EACH OCCURRENCE ❑EXCESS LIAR CLAIMS FADE AGGREGATE aDEDUCTIBLE Q RETENTION 3 q WORKERS COMPENSATION ■ OtE- AND EMPLOYEES LIABILITY mar wwlo THE PROPRIETOR/PARTNERS/ T.L. EACH ACCIDENT y 100,' A EXECUTIVE OFFICERS ARE ❑ incl 0 excl 7026049012012 05/26/2012 05/26/2013 1 E.L. DIs"sS-POLICY LINIT B.L. GIeS118E EA ENPLOTEE COLI MTS/DESCRIPTION OF OPERATIONS OR LOCATIONSS --- ----- CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF TIE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH T POLICY PROVISIONS. AUTHORISED RSPRtSENTATIVB�< —\ . 'A CERTIFICATE OF LIABILITY INSURANCE OATS{MMIDD/Y 12/6/20111 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 INSURER(S), AUTHORIZED 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 I 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). j PRODUCER NAME*CONTAC8t210x'1ne Thornton ..--;FAX._.. ..-- -.._..... ..__._ PHONE (4041653-0840 Atlanta International RMI Inc. 1 /C Nu,. ti;. (404)720-7546 - - .,(X—C No):(4 260 Peachtree Street NW E-MAIL Street, ADDRESS: Suite #2600 PRODUCER 00003932 _ CUSFOMER iD Its_—........ . .....___. _ �• Atlanta a GA 30303-1240 _ INSURER(S)AFFORDING COVERAGENAtC i/ INSURED _ ——- O. ..INSURER INSURERA_ Scottsdale Insurance C Michael Viola, DBA: Viola Roofing INSURER C: j B Hadassa Way INSURER D: i INSURER E: ! Hull MA 02045 INSURER F.- COVERAGES :COVERAGES CERMFICATE NUMBER:CL1112800641 REVISION NUMBER: II THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TNG 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 I{ CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 1S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIM11TO SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _.... _. STI6)2 POLICY EFF POLICY El(P i LTR I TYPE OF INSURANCE INS p�n POLI NUMBER MM1OD i MMiDDNYYY t LIMITS GENERAL LIABILITY EACH OCCURRENCE $_ 1,000,00 1 COMMERCIAL GENERAL LIABILITY I 6AMAUF7o RE X X ---.. ..._ PREMISES tEa otx n ncel •,$ 100,000 3. A CLAIMS-MADE �OCCUR X PS1456415 72/1/2011 2/?/2012 311 �........- MED EXP(Any one person)T S 5,000 PERSONAL$ADV INJURY $ 1,000,000 I GENERALAGGRE43ATE $ 2,000,000 f IGEMLAGGREGATE LIMrrAPPLIES PER: i PRODUCTS-COMP/OPAGG $ 2,000,000 X POLICY PRO-JECTLOC I -- $ .._ AUTOMOBILE LIABILITY I I COMBINED SINGLE LIMIT ANY § (Ee accident) _ BODILY INJURY(Perpetson) $ ALL OWNED AUTOS BODILY INJURY INJURY(Per accident) $ SCHEDULED AUTOS I PROPERTY DAMAGE HIREOAUTOS _ $ (.� .(Per accident) NON-OWNED AUTOS UMBRELLA UAB I s OCCUR EACH OCCURRENCE $ j EICCESS LIAB CLAIMS-MADE 1 AGGREGATE _ $ - DEDUCTIBLE $ RETENTION $ j S I WORKERS COMPENSATION WCSTATU- '0TH• AND EMPLOYERS,LIABILITY Y/N _ _ S. E ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT _ § OFFICERIMEMBER EXCLUDED? N/A I (MantletOry in NH) E.L.DISEASE-EA EMPLOYE $ If yes,descnbe Inder DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS S VEHICLES(Attach ACORD 101,Addltlonal Remarks Schedule,K more space Is required) TMD At-Acme Sex-vices, Inc and The Home Depot are included as additional insured with respects to General Liability Insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE iMTH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 26(2009109) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025 poosos) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 UV. www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): � C� �,,.�(�o)t W a- Address: Waq City/State/Zip: �kuk( Ma- 0Z04< Phone#: `7- O-Z S 3 Are you an employer?Check the appropriate box: Type of project(required): 1.[ I am a employer with -5— 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. # F]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 101-1 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.❑ Other *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: AT Policy#or Self-ins.Lic.#: -70z (,c7`( c) O (Z- O lZ Expiration Date: Z ~ (3 Job Site Address: [ 1�0 City/State/Zip: X-4 des lel � Ac, Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under 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 form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature:. _ Date: 7 Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 11 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. I� City or Town Officials 1 Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant jthat must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 �I www,mass.gov/dia Safety Insurance Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall North Andover, MA 01845 North Andover, MA 01845 RE: Insured: Daniel and Linda Burns Property Address: 131 Duncan Drive, North Andover, MA 01845 Policy Number: HMA0066519 Claim Number: BOS00011322 Date of Loss: 06/21/2010 Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number. Date of loss and claim or file number. Lisa Monette Date 6/21/10 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (800) 951-2100 x 3420 Fax: (617) 535-5833