HomeMy WebLinkAboutMiscellaneous - 215 FOREST STREET 4/30/2018 215 FOREST STREET
210/106.A-0076-0000.0
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Cunningham Lindsey U.S.,Inc.
P.O.Box 703689 Cunnin ham �' I
Dallas,TX 75370-3689 L1nCi Sey
Telephone(888)738-8714 Facsimile(214)488-6766
CLCAT@CL-NA.COM
*"*********************AUTO**3-DIGIT 018
776 T3 P1 95000058966
Building Commissioner or
Inspector of Buildings
120 MAIN STREET
N ANDOVER,MA 01845
_ Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS Ch. 139, Sec 3B
WA
Claim Number: 1248293 26
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Policy Number: 1248293 26
Company Name: BAY STATE INSURANCE COMPANY
CD
0) Cause of Loss: ICE DAM
g Date of Loss: 2/25/2015
F Insured: STEPHEN HATCH
0
Property Location: 215 FOREST ST
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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 3B is 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. No insurer shall pay any claims(1) covering the loss, damage, or destructions 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
perfect a 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.
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
Commonwealth of Massachusetts
FCEIVED
City/Town of JUL 2 8 2015
Syi tern Pumping.Record
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use�by local Boards of Health. Other forms may be*used, but the
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
1. System Location: Left/Right front of house, Left/ i rear�of nom, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(d different from location)
Citylrown - State Code
Telephone Number
B. Pumping Record �.
1. Date of Pumping Date 2. Quan. Pumped: Gallons3. Type of system: F1Cesspool(s) Septic Tank ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? ❑ Yeas No If yes,was it cleaned? ❑ Yes ❑ Na
' S. Condition of Sys m: I
U 6
6.. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo contents were disposed:
ALLS-0 Lowell Waste Water
Sign Haul Date f
t5form4.dol.-06/03 System Pumping Record•Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
GZ.�CV L (example: left front of house)
r, �� �jact- 0T—�c
215 �-0��5 SS—.
DATE OF PUMPING: •l -33-(51 QUANTITY PUMPED GALLONS
CESSPOOL: NO ZYES 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)
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SYSTEM PUMPED BY: c�5aZ
I
COMMENTS:
jLo!,
CONTENTS TRANSFERRED TO: G • .�•