HomeMy WebLinkAboutMiscellaneous - 200 BRIDLE PATH 4/30/2018M
'4WA
tr!i�j
ramft,
C.***
404
'-T
Phone. 978-632-2660
JAMES A. TRUDEAU
Fax: 978-632-2662
Adjustment Service Inc.
P. O. Box 7
Gardner, MA 01440
claims(a),trudeauad i.com
Notice of Casualty Loss of Building
Under Massachusetts General Laws, Chapter 139, Section 3B
December 31, 2013
Building Inspector
120 Main Street
North Andover, MA 01845
oard of Health
120 Main Street
North Andover, MA 01845
Fire Department
Dept. of Records
124 Main Street
North Andover, MA 01845
Insured:
Marie Dow
Loss Location:
200 Bridle Path, North Andover, MA 01845
Insurance Company:
Preferred Mutual Insurance Co.
Policy No.:
PHOO100781042
Date of Loss:
December 25, 2013
File Number:
13-11850
Claim Number:
13102363
Type of Loss:
Sewer Back -Up
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
BOARD OF HEALTH
27 CHARLES STREET
NORTH ANDOVER, MA 01845
TELEPHONE# (978) 688-9540
APPLICATION FOR ABANDONMENT
OF SUBSURFACE DISPOSAL SYSTEM
(SEPTIC SYSTEM)
Pursuant to Section 310 CMR 15.354
of the State Environmental Code, Title V
Name
Address
Contractor hired for work:
Name `
al -
Address /:6;- 7or
Phone
Phone
Date for scheduled abandonment 0 —3o —e o
The septic system at the above address has been abandoned according to
Title V specifications.
ZLJ
Signature o Contractor
Method of septic tank abandonment (check one). () removal () sandfill
00 crush ( ) other
C
Name of Offal Hauler
This form must he returned to the North Andover Board of Health.
PLEASE DO NOT WRITE IN THE SPACE BELOW FOR HEALTH
REPRESENTATIVE'S USE ONLY.
f1 c
66
C
Inspecting Agent Date
rc
" 31
N
0