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135 COACHMAN S LANE 1e
21{!Ior.4."07 0110
NEW ENGLAND CLAIMS SERVICE, INC.
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P.O. BOX 345 100 CONIFER HILL DRIVE, SUITE 308 P.O. BOX 578
MANSFIELD, MA 02048 DANVERS,MA 01923 SHREWSBURY, MA 01545
TEL. (508) 337-8058 TEL. (978) 777-9900 TEL. (508) 842-3995
FAX (508) 339-5835 FAX (978) 774-9296 FAX (508) 842-75_10 �{
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Form of Notice of Casualty Loss to Building �oAa
Under Mass. Gen. Laws, Ch. 139, Sec. 3D �r^
TO: Building Commissioner or Board of Health or -
inspector of Buildings Board of Selectmen
I o w �.► ��-ya-�L
addresses
RE: INSURED
PROPERTY ADDRESS
POLICY NO.:
LOSS OF:
FILE OR CLAIM NO.: 3
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 3D
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.
TITLE
On this date, l caused copies of this notice to be sent to the persons named above
at the addresses indicated above by first class mail.
fila.
SIGNATU E AND DATE
cc: Fire ept.
BOARD 014 HEALTH IUB IN L;: .�.
aoHKi; . �.
146 MAIN STREET
TELEPHONE# (508) 688-9540 ! (998
APPLICA TION FOR ABA NDOAVENT
OF SUBSURFACE DISPOSAL SYSTEM(
(SEPTIC SYSTEM)
Pursuant to Sectior. 310 CMR 1.1.354
of the Slate Environmental Code, Title V
Name Y,0� � �(ti C Q Phone
Address '11315 �'�a�t Wv W-3 11,0we
Contractor (tired for work:
Name Aid re�� 2�1 j;1617,. L Pe. Phone
Address
Date for scheduled abandonment
The septic system at the above address has been abandoned according to
Title V specifications.
Signature of Contractor
Method of septic tank abandonment (check one). ( ) removal ( } sandfill
V-crush ( ) other
Name of Offal Hauler ����
This form must be returned to the North Andover Board of Health.
PLEASE DO NOT WRITE IN THE SPACE BELOW FOR HEALTH
REPRESENTATIVE'S USE ONLY.
VKVI
Inspecting Agent Date
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