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Home My WebLink AboutMiscellaneous - 11 BEAR HILL ROAD 4/30/2018 T� j I I BEAR Hi�L ROAD 2101064.0-0021-0000.0 i Phone: 978-342-2660 Fax. 978-342-2699 JAMES A. TRUDEAU Adjustment Service Inc. P.O.Box 942 Fitchburg,MA 01420 claims()trudeauadi.com Notice of Casualty Loss of Buildint Under Massachusetts General Laws, Chapter 139, Section 313 April 29,2013 Building Inspector 120 Main Street North Andover,MA 01845 Board of Health 120 Main Street North Andover,MA 01845 Fire Department Dept.of Records 124 Main Street North Andover,MA 01845 Insured: John &Karen Vincent Loss Location: 11 Bear Hill Road,North Andover,MA 01845 Insurance Company: Preferred Mutual Insurance Co. Policy No.: PHOO100722478 Date of Loss: March 22,2013 File Number: 13-11532 Claim Number: 13004464 Type of Loss: Water Damage 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 writer and include a reference to the captioned insured,location,policy number,date of loss,and file or claim number. On this date,I cause copies of this notice to be sent to the person(s) named above at the address indicated by first class mail. Sincerely, Joshua M.Trudeau Claims Adjuster Commonwealth of Massachetts ---��- � ��® City/Town of �`� System Pumping Rec rd SEP 15 2005 Form 4 I \1 OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Other forms: b�u` dut ttae information must be substantially the same as that provided here. Before using this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: forms on the computer,use only the tab key Address, to move your cursor-do not use the return City/Town State Zip Code key. 2. System Ow er: Nam Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: 5-2,76Date Gallons 3. Type of system: ❑ Ces I(s) ❑ Septic Tank ❑ Tight Tank er(describe): 0- A 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6A5b 6. Syst Pumped By: Name Vehicle License Number i vb Coffipany 7. Location where contents were disposed: Si nat f Frauler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Address / 1 EA 2 �, �L_ P- 10, Title of File Page o f Date File Open: Date fele closed: DocjDocurnent/Action Title Date of Refer to other Purpose of Documennt/Action and notesaictiDocument/ document/ NumAction Department Board of Appeals — Board of Health — Planning Board — Conservation Commission — BUiiding Department WATERSHED RESIDENTS QUESTIONNAIRE 1. Name V,V 2. Street Address Pt LL ~ 3. How many members are in your household? 4. What type of sewage disposal system do you have? ❑ cesspool ❑ septic tank and leaching area connection to municipal sewer other (describe) ❑ do not know 5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health? ❑ yes ❑ no ❑ do not know 6. How old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years ❑ 11-20 years ❑ over 20 years ❑ do not know 7. Has your sewage disposal system been rebuilt or repaired? ❑ yes ❑ no ❑ do not know If yes, approximately how long ago? years. What was done? 8. How frequently is your sewage disposal system pumped out? Llannually • Elevery 2-4 years ❑ every 5-10 years ❑ over 10 years never 9. Have you had any problems with your sewage disposal system? ❑ yes ><no If yes, what problems? ❑ repeated pump-outs needed ❑ system clogs, backs up, or drains slowly ❑ odors ❑ sewage surfaces through ground 10. How many of each appliance are connected to your sewage disposal system? washing machine X dishwasher garbage disposal-55' dehumidifier drain sump pump toilet roof/pavement drains shower/bathtub _ 11. Please state the brand and type (liquid or powder) of detergent you use for: dishwasher clotheswasher 12. Does your property have a lawn? Xyes ❑ no If yes, approximately what size? ❑ less than 1/4 acre ❑ 1/4 acre V/z acre ❑ 3/4 acre ❑ 1 acre ❑ more than 1 acre (Specify) acres 13. How often do you fertilize your lawn? • No. of applications per year Season(s) of the year 14. Please state the brand and type (liquid or granular) of lawn fertilizer you use: Check here if your lawn is maintained by a professional landscape contractor. WATER,SHED:.RESIDENTS QUESTIONNAIRE Name GN fielIP!2fRC1 Street Address I 7 1/0/2, Ak:Lz- How many members are in .your household? What type of sewage disposal system do you have? LJ cesspool ❑ septk.tank and leaching area connection to municipal sewer other (describe) ❑ do not know Are the plans (drawings) for your sewage disposal system oil.file with the Board of Health? ❑ yes ❑ . no ❑ do not know 6. How old is your sewage disposal system?.❑ 0-5 years ❑ 640years ❑ 11-20 years ❑ over 20 years ❑ do not know 7. Has your sewage disposal system been rebuilt or repaired? ❑ yes ❑ no ❑ do not know If yes, approximately how long ago? years. What was done? 8. How frequently is your sewage disposal system pumped out? ❑ annually ❑ every 2-4 years ❑ every 5-10.years ❑- over'10 years never 9. Have you had any problems with your sewage disposal system? ❑ yes ><no If yes, what problems? ❑ repeated pump-outs needed `.L']_ system clogs, backs up, or drains slowly ❑] odors . ❑ sewage surfaces through ground 10. How many of each appliance are connected to your sewage disposal system? washing machine _ dishwasher. `�- garbage disposalx dehurnidifierldrain sump PUMP ., toilet .k roof/pavement drains shower/bathtub _ 11, Please state the.brand and type (liquid or powder) of detergent you use.for: dishwasher clotheswasher 12. :-,Does your.property have a lawn? yes ❑ no if yes; approx imately what size? Ness than '/a acre ❑ '/a acre /2 acre ❑ 3/4 acre _1 acre ❑ more than 1. acre (Specify) acres 13. How often do'you fertilize your lawn? No. of applications per year Seasoti(s) of the year 14 . please"sta'te the brand and type (liquid or granular) of lawn, fertilizer you use: Check,here if your lawn is maintained by a professional landscape contractor. RECE�VEC) SEP 16 2004 fQWI OF NORTH AN�-L� iod- SYSTEM HEALTH DEFT'DATE: OWNER&ADDRESS SYSTEM LOCATION nC��r (example: left front of house) V I11 o a k, I (. DATE OF PUMPING: QUANTITY PUMPEDt� GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: