HomeMy WebLinkAboutMiscellaneous - 14 SUMMIT STREET 4/30/2018 (2) ��14 SUMMIT STREET 1
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
FILE
TO: Building Commissioner or Board of Health or
Inspector of Buildings Board of Selectmen
Town of N. Andover ) ( Town of N. Andover
) (
N. Andover, MA 01845 ) addresses ( N. Andover, MA 01845
) (
(
RE: Insured: Douglas R. & Cynthia Berube
Property address: 14 Summit Street
North Andover, MA 10845
Policy No. HP 0208910
Loss of January 28, 1992
File or Claim No. WAP 14056(water)
Claim as been made Involving loss, damage or destructiontruction 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, CH. 139, SEC. 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. .
Adjuster
Title:
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.
PATRICK J. DONOVAN ASSOCIATES, INC.
P. 0. BOX 110 2/10/92
WAKFEILD, MA 01880
Sign ture a d date
J_c�/'�^`^^- 0
v
MAS�A�HU5�TTS
'�---� MA5SACHUSETTS
FIRE INCIDENT REPORT STATFIFI�� MAW-W-11_TH A| - FIRE DEpT___ ���~_�N1L_ .FORM Fp 7 �2
---------'--------------'---- - -�-d te - | day alarm t�m | arry tm ' ' in� / n serv |
| { fdid | incic|ent no^ | e«� ' a / 2 1647020 �` | Y 22:5� !
l | 10| XXXXX | 5418 | 0N | 03/03/g8l 3 ) 2 : o _
--- - -- - -- \ { ual aid i
| \ action taken mu�
{ situation found
s ua ' � --
| 48 | REMOVE�T}A�H�U .`
'! \ CO HAZARD
--- ---'' -' ' | |
� -=-^^` - --- -'--- 1 | ignition facto,`
1 fixed prnpertyRUUND i414 | LA{ K LU� MAl�T�WUHH [KJT ------ -156 \
��1L --'-' - --- �~ ' ---� - ---- !
-- --' -- ------- | zip codp | census
| correct addrcns
. \ 14 SUMMIT ST N' 7�}yER
AN
- \ tHephono | rnom o�` aut |
| | occup. name last, first " mi 7015 Op \ 14 |
' | 1 AS _ _ ___
' _ =����'��------------ - - ----' - | tplrc'honr |
-- l t fi t mi | address
| \ owner name as , rs ,
^ ` ' - ' - ' ��
| \ SAME
-12 --�Oc 'E--'---'-------------. -- - - -
method of alarm -|-' ' | di�,t�.`ict | shift i
| |
} 1�1| T E DIRECT TO FIRE DEPT A. 1.1 _1__ _ _ _� |- C - - i
' --�`�-�r���` -'- / #t job
| .�n-� ���' �#aerial app | �� other vehicles |
| | #fire service an ' �^ 9�''` � ' | W |
1 | uspd \ 0 | /� �'d
-- - - -- - l i used |
-- `- - - --' ' - | snec� a v�|o p s
| hazardous material | substance ' ^ ~ --
\ pr*�seqt : *YES*| CARBON MONOXIDE __ - \ 'CO UETECTOR |
- ' - -- ' ' '� �mber of fatalities | rescoes |
| numbers of injuries ! nu |
� \ -�mM-Bob=i-l�-e='p-r`=o-p~e-r-t--y -- -'{ | vehicle stolen--?_l|-'LeOsStSim_a_t- e-d �^0n|ta'
-l dollar
$p^ 00_
- �|'
-----------' - | �ntal insurance | claim paid |
| insurance company ` 0� |
| ____ __ ____ $0, 00 i '${D^
' '---'------------ - -' - -- | i # {
- - -'-------'k | model \color | lie no v n
| \ year ( ma e � ��
^ ' ---- - i
' -- | | i
--- --- ---- -- '---'--' |
-= ` - - - ' -
| model | serial no
| | if equip involved | year | make mo e
|
K�AFETY F
| ------'-----------'' -
��=``- --- - ��---�-���� in ignition |
| complex | } area o ' origin i equip inv
` '='=`-�=- ----^--'-------- \ |
� �'�--- | --material ignited
| form of heat zq»i ` zon ma ! form | type! FORM OF MA ) 99 \ WOOD. PAPER Ni 69 }
L | ID F | 16 | PELLE ____ __ _
-����- ' - --------' - - | |
| | level of fire oripin
\ method of extinguishment VE | g DE LEyEL TO g FT ABOVE GRAD | 1 ,
---------------' construction type\ | cons
| numbers of stories TECll� | 8 |
| 2 STORIES --- --D
' - -- -------' | extent o � smoke damage
|
| extent of flame damage \ NOT A STRUCTURE FIRE
N | N TRU[�TURE FIRE | 8- _
- '- ----' --- --- --- '- -' ' \ |
- - \ ! sprinkler| detector performance ler performanceIp pRES N/g) | 8 |
n | DET l�� SPA{ E OF ORIGIN-OPER _ _ i_1' l 'N{ ' EQU ��'L-� ' -' | |
' `- - - ' - | | type
| � f �'m smoke spread \ material qenerat inq | form ' '
� ~ u | | gg \ | 691
\ beyond room | most smoke : TL
.�WOOD PAPER |
S ORM MA x - _��_r��
'=- -- ---- --
-�L-������-------�-�������-----------' � -��pE�ING N CONSTRUCTION | 5 |
H i weather condit ions | aye _5mgkj� t���Y� ; '- �� _ '�' _ . - -
- - -- -- - t intended for |
| entries contained in this report are
| -------------------- E timat |
) CLEAR AND COLD \ The sole use of the state fire marshal. s -
| TEMP 35 | ions & evaluations made herin represent "MOST |
^ - " � effect, Any
|
� - ' | LIKELY" & "MOST PROBABLE cause e ec .
| as to the conditions outside the |
i ---------------- --------�| representationMhals Office is neither intended nor \
I | State Fire ars |
| member making report | implied
_ ................_-_''_
- �
CHECKLIST FOR CARBON MONOXIDE
Location of Incident: l// / Date of incident -2- y-S'P
QUICK CHECKLIST OF OCCUPANTS
Headache yes no v1 Fatigue yes no ✓
Nausea yes no ./ Dizziness yes no
Confusion yes no_z-
Are any members of the household feeling ill? yes no✓ GL>J
Do the residents feel better away from the house? yes no
Since the detector's alarm went off, what have you done?
Shut- off carbon monoxide sources yes ✓ no
If yes which sources �e t S�0F
Let in fresh air? yes no
If yes how did you let the air in --j-)a.b t- S u
How long did you let the air in a M e
PPM reading ambient outside the dwelling
Highest PPM reading in the dwelling o m
Carbon monoxide detector present? yes no
If yes list the number of detetors locations and make, and serial number of each below.
lt- '7Y 0,h/
2.
3.
4.
Which detector(s) by number above activated?
SOURCE CHECKLIST LOCATION PPM READING
Chimney clogged flue, blocke _ ening 4,1 1 DKII 1 Pi0y^-
Fireplace(s)rr__ Natural gas, LPG, ood(i dicate type for e h fireplace)
Wo DD IS7 U0 e e-! I
Gas Appliance (if Gas Company on Scene they can perform this check)
(IF MORE THAN 1 OF THE FOLLOWING APPLIANCES LIST EACH ADDITIONAL
ON THE COMMENTS PAGE WITI-I ITS LOCATION, AND PPM READING)
refrigerator ��eL"F''` <---
stove
vent over stove �-
clothes dryer -�eLt''`�-
water heater �-
fiirnace �-
Oil burner Non,
car garage
Entranceway from garage to house
Name of individual operating the CO monitor
Person completing the Checklist