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Cunningham Lindsey U.S., Inc.
P.O. Box 703689
Dallas, TX 75370-3689
Telephone (9 88) 738-8714 Facsimile (214) 488-6766
CLCAT@CL-NA.COM
***********************AUTO**3-DIGIT 018
797 T3 P1 95000058987
Building Commissioner or
Inspector of Buildings
120 MAIN STREET
NORTH ANDOVER, MA 01845
Claim Number:
Policy Number:
Company Name:
Cause of Loss:
Date of Loss:
Insured:
Property Location:
Cunnin ham
Lindsey
Form of Notice of Casualty loss to Building
Under MASS. GEN. LAWS Ch. 139, Sec 3B
3077140
3077140 00
MERRIMACK MUTUAL FIRE INS
ICE DAM
2/19/2015
YVONNE & DARREN MERRILL
103 PHILLIPS CMN
Claim has been made involving loss, damage, or destruction of the above captioned property, which
may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be
applicable.
If any notice under Massachusetts General Law, Chapter 139, Section 313is appropriate, please direct it
to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss
and claim number.
Section 3B'rNo insurer shall pay any claims (1) covering the loss, damage, or destructlons:to a building or
other structure, amounting to the one thousand dollars or more, or (2) covering any loss; damage or
destruction of any amount, which causes the condition of a building or other structure to render section
six of chapter one hundred and forty-three applicable, without having at least ten days previously given
written notice to the building commissioner or inspector of buildings appointed pursuant to the state
building code, to the fire department or arson squad of the city or town and to the board of health or
board of selectmen of the city or town, in which the same is located. If at any time prior to the payment
the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to
perfecta lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or
section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not
be made while the said proceedings are pending; provided, however, that said proceedings are initiated
within thirty days of receipt of such notification.
C
Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and
forty-three or section one hundred and twenty-seven B of chapter one hundred and eleven, shall
extend to and may be enforced by the city or town against any casualty insurance policy or policies
covering any loss, damage, or destruction pursuant to which the proceedings to perfect the lien were
initiated.
No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested
party for amounts disbursed to a city or town under the provisions of this section, or for amounts not
disbursed to a city or town under the provisions of this section.
On this date, I caused copies of this Notice to be sent to the persons named above at the addresses
indicated above by First Class Mail.
Cunningham Lindsey
Catastrophe Department
cicat@cl-na.com
800-867-3885
L C 0,J {i9 n It, A-)
'- No. Ili Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ :16. Lill—
Building/Frame Permit Fee $
AMUS
Foundation Permit Fee
/® G'� �Q`Other Permit Fee $
�er Connection Fee $ ' '•?- 2.1- i L
6',) Water Connection Fee $ ?1)"T ?1- �y
t" �„ TOTAL $ I i t, , cn>
/0, ,
`A�.��
k,�{;
Building Inspector
Div. Public W--"
Ldtation
N�. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
1.Sewer.Conn6ction Fee $
A 4
Water Connection Fee $
Building Inspector
Div. Public Works
tai 6
� Location e tki1�A4
Iio. / V
Date
TOWN OF NORTH ANDOVER
Sewer-Cdnnection Fee $
fowl Water Connection Fee $
'
0/ h JJ�A�'t�,.��lJ/ _ �.�• u� � ° _ Bu(cling Ins actor
d
7/1
Div. Public Works
A Certificate of Occupancy $
Building/Frame Permit Fee $
1�sACMUSE�� Foundation Permit Fee $
Other Permit Fee $
Sewer-Cdnnection Fee $
fowl Water Connection Fee $
'
0/ h JJ�A�'t�,.��lJ/ _ �.�• u� � ° _ Bu(cling Ins actor
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Div. Public Works
Aja
�� fITNO. Jz
a.
APPLICATION FOR PERMIT TO BUILD —NORTH ANDOVER, MASS. lu J�
MAP KVO.
LOT NO.
I
2 RECORD OF OWNERSHIP IDATE
BOOK 'PAGE
ZONE
SUB DIV. LOT NO.
—
LOCATION '�_'
-4-
M3
PURPOSE OF BUILDING
OWNER'S NAME 4
NO. OF STORIES f/rk - SIZE rl a„
OWNER'S ADDRESS 1)33, /L.L. Y�$ /lii^1�I,'a/
�, Y
i 1, ice,
BASEME R SLAB
ARCHITECT'S NAME «\i ��L
w
SIZE OF FLOOR TIMBERS 1ST" //1 2ND %)C 3RD
BUILDER'S NAME r
SPAN
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS 7
DISTANCE FROM STREET
---
POSTS
(�f-
DISTANCE FROM LOT LINES - SIDES rlA
REAR�%�
GIRDERS
AREA OF LOT f L`
l tDNC
FRONTAGE 1Qo
/y
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW
SIZE OF FOOTING r X _
IS BUILDING ADDITION wo
MATERIAL OF CHIMNEY R. Irrll�_ _
IS BUILDING ALTERATION- IJD
t
IS BUILDING O OLID R FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF
CODE id
`%S
IS BUILDING CONNECTED TO TOWN WATER is
BOARD OF APPEALS ACTION. IF OF APPEALS ACTION. IF ANY
_t
IS BUILDING CONNECTED TO TOWN SEWER
BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE Ile11?
INSTRUCTIONS
m'!b4 rwl�1p
Ri�J:OT�A�(�ac.
SEE BOTH SIDES
PAGE 1 FILL OUT SECTIONS i - 3 �f
D /� � M10�/®� ie /
s �fri.�fff/rrr
PAGE 2 FILL OUT SECTIONS 1 - 12
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING % j-�0 �)
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REMI msT FE y����� �" v i, V
1� PLANS MUST BE FILED AND APPROVED BY BUILDING IN4. FDA FEE— ,._aL 0 49, 1) 0
(11 .+ DATE FILEDDUEF(!Q� ��I��!`! %f6je, V O
I
SIGNATURE OF OWNER OR AUT ORIZ NT
FEE
PERMIT GRANTED
e J,3 19
PERMIT FOR FRAME/BUILDING
DATE: fEE PAR.-�
y
�3 '2 ,5 W, "Y' 13 7 57,
OWNER TEL. 4(Og7/ (2a
CONTR. TEL. #tY
CONTR. LIC. #
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST , 5�
EST. BLDG. COST PER SQ. FT.,
EST. BLDG. COST PER ROOM J V
SEPTIC PERMIT NO. /
4 APPROVED BY ✓C�
BOARD OF HEALTH
PLANNING BOARD
BOARD OF SELECTMEN
BUILDING INSPECTOR
r
BUIL-D-1NG RECORD
1 OCCUPANCY:..12 - '; ; ,
j
SINGLE FAMILY
STORIES
MULTI. FAMILY
OFFICES. �_
APARTMENTS
CONSTRUCTION
M
2 FOUNDATION
I
Ley
8 INTERIOR FINISH
CONCRETE
PINE
3
1
2_
I_.
CONCRETE BL'K.
BRICK OR STONE
HARDW'D
PLASTER
_ DRY WALE.
UNFIN.
_
_
PIERS
3 BASEMENT
AREA FULL FIN. B'M'TAREA,
'/. +/2 1/.
FIN. ATTIC AREA
NO BM'T
FIRE PLACES -->
HEAD ROOM
MODERN KITCHEN
A
4 WALLS I ;9 "•, FLOORS
CLAPBOARDS
DROP SIDING
WOOD SHINGLES
ASPHALT SIDING
ASBESTOS SIDING
�,
CONCkETE
DEARTH
HARMU'D
COMMCN
ASPH. TILE
B
1
2
�_
3
_
_
VERT. SIDING
_
STUCCO ON MASONRY
STUCCO ON FRAME
nkl
BRICK ON MASONRY
BRICK ON FRAME, ti'L
ATTIC STRS. & FLOOR I_
CONC. OR CINDER BLK.
WIRING
STONE ON MASONRY ,
_
STONE ON FRAME,SUPERIOR
ADEQUATE I7CI I NONE
10 PLUMBING
5 ROOF
GABLE
HIP
BATH (3 FIX.)
GAMBREL
MANSARD
TOILET RM. 12 FIX.)
FLAT
SHED
WATER CLOSET
ASPHALT SHINGLES
LAVATORY
_
WOOD SHINGES
KITCHEN SINK
_
_
SLATE
NO PLUMBING
TAR & GRAVEL
STALL SHOWER
_
ROLL ROOFING
MODERN FIXTURES
_
TILE FLOOR
_
TILE DADO
6 FRAMING I
11 HEATING
WOOD JOISTPIPELESS
FURNACE
74
FORCED HOT AIR FURN.
TIMBER BMS. &COLS.
STEAM
STEEL BMS. & COLS.
HOT W'T'R OR VAPOR
WOOD RAFTERS
AIR CONDITIONING -
RADIANT H'T'G
UNIT HEATERS
7 NO.� OF ROOMS
GOAL
B'M'T 2Nd
1st 13rd;'. I
ELECTRIC" =� \
NO -HEAT 1,N 9� \ .i
A
THIS SECTION MUST SHOW EXACT i0IMENSIONSOf LOT AND DISTANCE FROM
S
'LOT -LINES'AND EXACT DIMENSIONOF BUILDINGS:' WITH 'POR;aHES. GA-
RAGES. ETC. SUPERIMPOS;ED:'TH'IS REPLACES, PLOT. PLAN.,
'+�. �� s .srsrw�wswrrir� wY Bit:.'
t'll
e
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having
have been obtained. This does not relieve the applicant land oron
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: S Phone 6 7
LOCATION: Assessor's Map Number Parcel
r.
Subdivision �� �y-r�S �r�,c Qrn_ Lot (s) c�
Street
St. Number
Use Only************************
RECO DATIONS OF TOWN AGENTS.
\ Date A
Conservation Administrator ejected 13
Date Rejected
Comments
To n Planner Date Approved `-' 1Zj •C -J7_
Date Rejected
Comments
HealthDate Approved
Agent Date Rejected
Comments
Public Works - sewer/water connections
driveway p=ermiDt
Fire Dena A- /1--
Received by Building Inspector
Date
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