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MetLife Auto & Home®
Homeowner Operations Field Claim Office
Mail Processing Center
P.O. Box 2201
Charlotte, NC 28241
(800)854-6011
Mettife
July 21, 2014 RECEI D
North Andover Health Department � 4 2014
1600 Osgood St TOWN OF NORTH ANDOVER
Suite 2064 HEALTH DEPARTMENT
North Andover, MA 01845
Our Customer:
Karen A Busanovich Trust
Claim Number:
JDE49828 4X
Date of Loss:
July 15, 2014
Dear Sir or Madam:
Pursuant to M.G.L. 139 § 313, please be advised that a property loss at the address referenced below has
been estimated to have damage to the dwelling or other structures that will exceed one thousand dollars.
Please let us know within ten (10) days if there is a pending or existing lien against the property as
provided by M.G.L. 139 § 313, or if there is an intent to initiate proceedings to perfect such a lien.
Loss Location: 249 Rea St, North Andover, MA
Sincerely,
Larry Branco – FLD - DR
Metropolitan Property and Casualty Insurance Company
Senior Claim Adjuster -_
(800) 854-6011 Ext. 7177
Fax: (866) 958-0736
Email: lbranco@metlife.com
MetLife Auto 8 Home is a brand of Metropolitan Property and Casualty Insurance Company and its affiliates, Warwick, RI.
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has provided this form for use by local Boards of Health. The System Pumping Record must
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mping Record .
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http://www.mass.gov/dept*nater/apprpvals/t5forrns.htm#inspect
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FORM - U - LOT RELEASE FORM
INSTRUCTIONS:. This form is used to verify that all -necessary approval / permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve the
applicant and or landowner from compliance with any applicable requirements.
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APPLICANT — 5� �`o�,� /��'�•r PHONE
ASSESSORS "NUMBER ,pica LOT NUMBER 61
SUBDIVISION LOT NUMBER G e' 7-/�
STREET r ��I'�le ' ....................... STREET NUMBER
OFFICIAL USE ONLY
ECONWENDATIONS OF TOWN AGENTS
ATION
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TOWN PLANNER
COMMENTS
FOOD INSPECTOR - HEALTH
SEPTIC INSPECTOR - HEALTH
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COMMENTS A h&,44 v Y
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DATE APPROVED
REJECTED 31 % 103
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PUBLIC WORKS - SEWER I WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
COMMENTS
RECEIVED BY BUILDING INSPECTOR
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED/U-
DATE REJECTED
DATE APPROVED
DATE REJECTED
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:y /8 -O /
SYSTEM OWNER & ADDRESS
do J/
SYSTEM LOCATION
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DATE OF PUMPING: QUANTITY PUMPED GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES (�
NATURE OF SERVICE: ROUTINEy
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:_
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NAME OF LOT OWNER ADDRESS
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Soil Loa: To-osoil Subsoil Deaths &. Tvnes
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Signature --acA�L
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Time to Time to
rerc Tests ueptn Saturation !Yme Drop 12" - 9" Drop 9" - 6"
Other Considerations:r�/��
Recommendations:
Signature --acA�L
TOWN OP NORTH ANDOVER
ADDRESS OF SYSTEM!
NAME OF PROFESSIONAL ING=
NAME OF LOT OWNER
NORTH ANDOVER BOARD OF HEALTH
REPCET OF PERC TEST
L.11 '4 �� _ DATE - %
OR SANITARIAN CONDUCTING TESTS
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SHOW APPROXIMATE LOCATION OF PITS ON SKETCH ON REAR OF THIS SHEET
Total
Soil Log: Tomsoil ; Subsoil Depths & es Water Level Pit DeptI.I.
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Time to Time to
Pere Tests Depth Saturation Time Drop 12t1 - 9}1 Dron 9t1 - 611
Other Considerations:
Recommendations:
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Signature
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Other Considerations:
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