HomeMy WebLinkAboutMiscellaneous - 253 APPLETON STREET 4/30/2018TO
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C�ETALL RNED
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URGENT ❑
DEC -11-01 TUE 02:45 PM DAVID.,_,G-,MELANSN 508 256 6206 P.01
�n.P. - ¢age 6Tructural Wooer P+ad. 979 S39 21a� 12!@6!01 12r47F P.6¢17
Willamette Industries, Inc. -
E.ngineer*d vv000 Products NORTHEAST STRUCTURAL WOOD PtiRODUCT8
JOB NAME: nAarr
E -Z (-,aiG (4,0.3-R) Lor,ArroN
J06 Na. Firsl Jab p_0"Ek SHE Vit'
MARK ®am 1 Flow Joist
'>i rib; 16 in. Input W10CIS norizontal center to oarges spans
W1 a 07 Plf LL - 40psf Ok = 10 gsf Duration = 104' 5
LOADS
SWEAR
MOMENT --.-
Maximum Reactions
Support I Support 2
C'•r;4icai Live Load; (DOL)
533 (100) 533 000)
Dead lam.
133 133
BA Ailow. Maxirrlum
Allow.
DOL - Control
Sheaf: ( lbs)
47% t,67
1420
9040%0 - Ail Loads
positive Mom nt: (ft4tm)
77% 3333
4335
900% -All Loads
Defiotlion
LL Ratio 7L
0.526 11456 0.658
Ratio
11365
Ei X396x 108 K 6.18 x 10a
spats:
�** USE 11.675 INCH PRI 60 @16
in. QIC
Min aetd roquib4OVInge m l be ringssW bottomaneva ed9a�a a load defla fton meats code b� may xcesd Wiilametta a La4arAt
support regt�irad at bearings .
t�acOnasraersrlationa.
The pi a,te r+oted ars 1rn&rid+tl tar IrvIdrlAr uGe, nOrm+1 te��1p0ra1ura8, un9'eeted apt�;icdi4an9 and must he Inet+s�ad N BaeordaneV vvftlt kcal f,lildlnp Codd AeAkAftPrP>++ert40
end tri}Ikrm'no it'd sl►tae. inc. rdcommandellons, it�fe cghulA6mn trllee!a the epeu+�c dC��v91de4 s a d etk fnlannae6an�iwteti eN iid be reg"%4 0 6)W of *4 nd
manuPetrt+xEd by WiAetnetta tns�r�tries, N1C, The bade. sptrtx a+rd epac hev4 beero►ps �1I
a.. vatdrtcd tar the accut+cy end e+tilebiMty ar aA deNgn A®oelndters �n4 product 9e16Ctlarle.
I 4 / I70A *I K TX f r- / PC,) Q-
Date ' .: /J -c i.
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ..,� .?... �� . �7 ...:................. .
has permission to perform ..... C. t.
plumbing in the buildings of ... ....r ................... .
at. %.� ` �.'^ ............ . .North Andover, Mass.
Fee..��U' . r.. Lic. No.. 1 f.
1 .I -.' ...........
PLUMBING INSPECTOR
Check # y y
5139
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date
Building Location JS j 4�(jLt O,J Owners Name �� oJC !S ^� Permit #
Y
Amount
TVDe of Occunancv
New Renovation ri
Replacement
FIXTURES
Plans S�bmitted Yes [],-00" No ❑
(Print or type)g Check one: Certificate
Installing Company Name ; � j� } �-/,�.(/ 'A G, ❑ Corp.
Address AX S G C F -� � Partner.
Business Telephone Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy ❑ Other type of indemnity ❑ Bond
Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner Agent El
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Mas achusetts Stat, PI robin Code and Chapter 142 of the General Laws.
�=
BY igna ure o ice se um er '
Title
Type of Plumbing License
D I '
City/Town �cenL�m er Master ❑ Journeyman APPROVED (OFFICE USE ONLY 0
3566
Z
-
Date . ... 0
.....
...................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ..........
......................................
..............................
has permission to perform ............
... .........
wiring in the building of ......... ..................................................
at n� ..... i ....... North Andover, Mass.
Fee� . ............. i ANo. ............. ........ . ...............................................
Check# '�- - ��/ ELECTRICAL INSPECTOR
Official Use Only
Permit No. '56 "-(,a
I aq- S Occupancy & Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS.527 CMR 12:00
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00 ci
(Please Print in ink or type all information) Date
To the Inspector of Wires:
Town of North Andover
ThP ajndersinned aoolies for a Dermit to DerForm the electrical work described below.
Location(
Owner or
Owner's Address
Is this permit in conjunction with a building permit YesNo ❑ (Check Appropriate Box)
znw i
Purpose of Building
Existing Service + � 40 ler, 01
Amps � C 0 Volts
New Service Amps Voits
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
Overhead ❑
Authorization No.
Undgmd No. of Meters
Overhead ❑ Undgmd ❑ No. of Meters
OTHER: lJ 6=!4
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO =
have submitted valid proof of same to the Office YES = NO = If you ave checked Y.PS please i 'cate theme of coverage by checking the appropriate box
INSURANCE= BOND = OTHER = (Please Specify)
piratioh Date)
Estimated Value of EI cal Work$ /
Work to Start d R InspectiogWte Resquested Rough Final
Signed under the Penalties of perjury: i ;7 n i J ^7
FIRM NAME LIC. NO.+G1 % �l
r
Liikensee �Signature LIC. NO.
Address C 6 CG�" 41L' � LBAft Tel. No. `
OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have:the insurance coverage or its substantial equivalent as required by Massachusetts
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
Telephone No. PERMITTEE $/J --O
(Signature of Owner or Agent)
Total
No. of Lighting Outlets
No. of Hot fuse
No. of Transformers KVA
No. of Lighting Fixtures /
Above ❑ In ❑
Swimming Pool gmd ❑ grnd ❑
Generators KVA
No. of Emergency Lighting
No. of Receptacles Outlets 17
No. of Oil Burners
Battery Units
No. of Switch Outlets
No of Gas Burners
FIRE ALARMS No. of Zone
No. of Detection and
Total
No. of Ranges
No of Air Cond
Tons
Initiating Devices
Heat Total Total
No. of Di osal
No.
Pumps Tons
KW
No. of Sounding Devices
No./ of Self Contained
No. of Dishwashers
Space/Area Heating
KW
Detection/Sounding Devices
❑ Municipal ❑ Other
No. of Dryers
Heating Devices
KW
Local Connection
No. of
No. of
Low Voltage
No. of Water Heaters KW
Signs
Bailases
Wiring
No. Hydro Massage Tuds
No. of Motors
Total HP
OTHER: lJ 6=!4
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO =
have submitted valid proof of same to the Office YES = NO = If you ave checked Y.PS please i 'cate theme of coverage by checking the appropriate box
INSURANCE= BOND = OTHER = (Please Specify)
piratioh Date)
Estimated Value of EI cal Work$ /
Work to Start d R InspectiogWte Resquested Rough Final
Signed under the Penalties of perjury: i ;7 n i J ^7
FIRM NAME LIC. NO.+G1 % �l
r
Liikensee �Signature LIC. NO.
Address C 6 CG�" 41L' � LBAft Tel. No. `
OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have:the insurance coverage or its substantial equivalent as required by Massachusetts
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
Telephone No. PERMITTEE $/J --O
(Signature of Owner or Agent)
Location
No. Date �� 12- ,o
MOPTI, TOWN OR NORTH ANDOVER
.. 9
Certificate of Occupancy $
ria
CHUS Building/Frame Permit Fee $
CM
Foundation Permit Fee $
' Other Permit Fee $
TOTAL $ 2 5
Check # --5-
15250
-5-
15250 Building Inspector
41
N_.e^ , 4 .
Of
► SECTION 1- SITE INFORMATION ►
Date
1.1 Property Address:
5 3 6(?p �► s�
1.2 Assessors Map and Parcel
�� � O
Map 'Number
Number:
Parcel Number
Signature I Telephone
1.3 Zoning Information:
a,
Zoning District Proposed Use
2.2 Owner of Record:
Name Print
1.4 Property Dimensions:
Lot Areas e
1 __) 01
Frontage ft
1.6 BUILDING SETBACKS ft
r
SECTION 3 - CONSTRUCTION SERVICES
Front Yard .
Side Yard
3.1 Licensed Construction Supervisor:
Licensed'Construction Supervisor:
Address
Signature Telephone
Rear Yard
RegWred Provide
Ropired Provided
ReqWred
Provided
1
Not Applicable ❑
1.7 Water Supply M.G.LC.40. 54)
Public ❑ Private ❑ Zone
1.5. Flood Zone Information:
Outside Flood Zone ❑
1.8
Municipal
Sewerage Disposal System:
❑ On Site Disposal System 0
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
Name (Print)
-+i�L
Address for Service
Signature I Telephone
2.2 Owner of Record:
Name Print
Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed'Construction Supervisor:
Address
Signature Telephone
Not Applicable ❑
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
_
Expiration Date
Sip-natun6 Telephone
f
F
i
A'.
SECTION 4. - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application.
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......0 No ....... 0
SECTION 5 Description of Proposed Work check all applicable)
New Cttuction ❑ Existing Building ❑ Repair(s) ❑ eratios)
,0
Accessory Bldg. ❑ I Dem°blition ❑ Oth ❑ peci
Brief Description of Proposed Work: N6
I SECTION 6 - ESTYMATF.D CONSTRUCTION COSTS 1
to provide this affidavit will result
M I Addition,M
Item
Estimated Cost (Dollar) to be
94,
Complete by permit applicant
ry
ot.
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) X (b)
a-
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, HK7,lg to L 15 n'1 2 S� , as Owner/Authorized Agent of subject property
Hereby authorize to act on
My !Ifin Imatt relayve to work authorized by this building permit application.
/0')
J d
Signature of Owner Date
SECTION 71b OWNER/AUTHORIZED AGENT DECLARATION
I, ,as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print Name
r.
Si ature of Owner/Aent Date
_'01111111111111 1111
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TDvIBERS 1ST 2ND 3
SPAN
DEMENSIONS OF SILLS
DM4ENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
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Location :;2S, PPI f40 A)
No."�"''', 1 _ Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ CCi�rr
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $ Ll
TOTAL $ %
Check # -�-Sola
15137 Building Inspector
•" r 1 "�,l.lxL .Vv
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
z Yy ,� L S '3au5A� �rI �+d e i`'' 's' S S Y `(j ```Y4•f" s ¢. g°W
.>➢'<�y;�ct`'��'n ...
BUILDING PERMIT NUMBER: � Cf � DATE ISSUED: Y f
SIGNATURE: II'
Building Commissioner/12tEtor of Buildings Date
SECTION 1- SITE INFORMATION
1.1 . Property Address:
1.2 Assessors Map and Parcel Number:
GS- i6S'
Map Number Parcel Number
1.3 Zon
1.4 Property Dimensions:
Zonin Distrid
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide Required=
Provided
Required Provided
Flood 000ne Information: 1.7SVater SupptyM.G.L.C.40. 54) ].
d Z f
Publi) ❑ Private 0 Zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Qwner of Record
T-12-lnlc:,ts �Y. A-Af_(L a53
Name (Print) Address for Ser,70
= I P, (9?7) os -G -)O
Signature I Telephone
2.2 Owner of Record:
Name Print , Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor:
License Number
Address
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
111
2
C
f
SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......❑ No ....... 0
SECTION 5 Description of Proposed Work check all a licable
New Construction ❑ 1 Existing Building ❑ 1 Repair(s) ❑ Alterations(s) ❑ Addition
Accessory Bldg. ❑ I Demolition ❑ I Other ❑ Specify
Brief Description of Proposed Work:
-A IACA \ ,J,,- ) 2v � � �o r✓►� � L h
hovsp
I SECTION 6- RSTIMATED 6 ONCTRU TInN f nCTC I
Item
Estimated Cost (Dollar) to be�
Completed by permit applicant
O»lFiCiALUSE
i
x:�.-s�'. ;flag
ONl1.�
1. Building
(a) Building Permit Fee
Multiplier "
2 Electrical
-7oQ
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (el X (b)
4 Mechanical HVAC
5 Fire Protection
6 Total1+2+3+4+5
Check Number
z is VW11E'KAU1nVKIL.AIIVIV 1V 13h CUYWLhlEll WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
Date
1, as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print Name
Signature of Owner/Agent Date
s
EE -7
n1o.3(j76p !,
0
�ms��/STER�Q�rQ'
�NAf LAHD�J
AMERICAN SURVEYING COMPANY
OF BOSTON, INC..
1264 MAIN STREET WALTHAM, MASS. 02451
REGISTERED LAND SoU,-RVEVEYOR, PHONE (781) 893-6477 FAX (781) 893-7091
AP P LF -7-0 t�1
30780
0
>TEV�I
LA14 o/
�p f 2C�l0
> REGISTERED LAND SURVEYOR,
)0 HEREBY CERTIFY THAT THE
\BOVE MORTGAGE INSPECTION
'LAN WAS PREPARED FOR
e
ST'R EET
I" -6(z>'
AMERICAN SURVEYING COMPANY
OF BOSTON, INC.
1264 MAIN STREET WALTHAM, MASS. 02451
PHONE (781) 893-6477 FAX (781) 893-7091
MORTGAGE INSPECTION PLAN
TITLE AMERICA
DATE: - 6/28/01
RECORDED AT: ESSEX COUNTY REGISTRY OF DEEDS
CLIENT: TITLE AMERICA
N CONNECTION WITH ANEW
CLIENT REF.#: OtMS1035
BOOK: 3548 PAGE 3$_ L.C. CERT #
PL 10282
OR E, AND IS NOT INTENDED
J,0 #; 60072201
PLAN REFERENCE:
EPR
1R REPRESENTED TO BE A LAND
THE LOCATION OF THE ORIGINAL
DRAWN PER TOWN OF: ASSESSORS
MAP#: PARCEL#: DATED:
OR PROPERTY SURVEY. NO
DWELLING SHOWN HEREON EITHER
ADDRESS: 235 APPLETON ST. NORTH ANDOVER, MA
CORNERS WERE SET, AND IT
WAS IN COMPLIANCE WITH LOCAL
BORROWER: MARR
CANNOT BE USED FOR
APPLICABLE ZONING BYLAWS IN
ESTABLISHING FENCE, HEDGE,
EFFECT WHEN CONSTRUCTED
OR BUILDING LINES. THE LAND
(WITH RESPECT TO HORIZONTAL
SHOWN ,HEREON IS BASED ON
DIMENSIONAL REQUIREMENTS ONLY),
CLIENT FURNISHED
OR IS EXEMPT FROM VIOLATION
INFORMATION, AND MAY BE
ENFORCEMENT ACTION UNDER MASS
THE SUBJECT DWELLING LIES IN FLOOD ZONE X
SUBJECT TO FURTHER
G.L. TITLE VII, CHAP. 40A, SEC.7
AS SHOWN ON THE NATIONAL FLOOD INSURANCE PROGRAM—
OUT-SALES, TAKINGS, EASMENTS,
UNLESS OTHERWISE NOTED OR
INSURANCE FLOOD RATE MAP DATED: 6/2/93
AND RIGHTS OF WAY. NO
SHOWN HEREON.A CONFIRMATORY
COMMUNITY / PANEL #: 2500980006C
RESPONSIBILTY IS EXTENDED
INSTRUMENT SURVEY IS ADVISED
HEREIN TO THE LAND OWNER OR
WHEN STRUCTURES ARE SHOWN
I FIELDED I DRAFTED CH ED
OCCUPANT. IT IS NOT INTENDED
LESS THAN 1' FROM PROPERTY OR
BY:
MJH
TO BE RECORDED...
REQUIRED ZONING SETBACK LINES.
DATE: 16/23/01 F.B. PGE:
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FORM U LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
*****************************APPLICANT FILLS OUT THIS SECTION***********************
APPLICANT �A ri M A �� PHONE`l �� 6 � S v ��
LOCATION: Assessor's Map Numbers �' PARCEQ�6 /
SUBDIVISION LOT (S)
STREET �—rs�`J ST. NUMBER as3
*****************************************OFFICIAL USE
ONLY***********************************
OF TOWN AGENTS:
VAT IO)TAbMINISTWATOR DATE APPROVED
DATE REJECTED
COM
TOWN PLANNER
COMMENTS
9
DATE APPROVED
DATE REJECTED
.,
FOOD INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
i SEPTIC INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
COMMENTS
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9\97 jm
D. Robert Nicetta
Building Commissioner
(978) 688-9545
1978) 688-9542 Fax
Building Department
27 Charles Street
North Andover, MA. 01845
HOMEOWNER LICENSE EXEMPTION
Please print
DATE
JOB LOCATION 5 ?Q � _
I -^0 N
Number -U Street Address
"HOMEOWNER r12A I'd K N a (`6< - O i F
Name Home!
PRESENT MAILING ADDRESS S 3 ►���, {� J
City Town
Nt �
State
. d
� 9
�z� x
SgCHU58�
Map / lot
B 0 gg
Work Phone
8�s
Zip Code
The current exemption for "homeowners" was extended to include owner -occupied dwellings
of two units or less and to allow such homeowners to engage an individual for hire who does.
not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1)'
DEFINITION OF HOMEWOWNER:
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which
there is, or is intended to be, a one or two family dwelling, attached or detached structures ac-
cessory, to such use an farm structures. A person who constructs more than one home in a
two-year period shall not be'considered a homeowner.
The undersigned "homeowner' assumes responsibility for compliance with the State Building Code and other
Applicable codes, by-laws, rules and regulations,
The undersigned "homeowner" certifies that he/.she understands the Town of No. Andover
Building Department minimum inspection procedures and requirements and that he/she will
comply with said procedures and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING OF
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11,S150A.
The debris will be disposed of in:
�ab� aus a) -YY) t,I 1
(Location of Facility)
Signature of Permit Ap licant
//? A I
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
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FORM OF NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASS GEN. LAWS CH 139 SEC 3B
TO: BUILDING COMMISSIONER OR BOARD OF HEALTH OR-,ji
INSPECTOR OF BUILDINGS BOARD OF SELECTMEN a.
North Andover Town Hall North Andover Fixe -Department
120 Main Street ADDRESSES 124 Main Street
North Andover, MA 01845 North Andover, MA 01845
ATTENTION: FIRE PREVENTION
RE: INSURED:
PROPERTY ADDRESS: 253 Appleton Street C,
North Andover MA 01845 ,
POLICY NO. HMA 0015183
LOSS OF Jewelry Loss on December 13, 2003
FILE OR CLAIM NO. DA0312046F
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 ATTENTION OF THE WRITER AND INCLUDE
A REFERENCE -TO THE CAPTIONED INSURED, LOCATION, POLICY NUMBER, DATE OF LOSS AND
CLAIM OR FILE NUMBER.
SIGNATURE Te ry M. Seger
T.M. SEGER CLAIM SERVICE, INC.
459 Washington St - PO Box 277 - Duxbury, MA 02331
Telephone (781) 934-9770
Fax No. (781) 934-9194
ON THIS DATE, I CAUSED COPIES OF
ABOVE AT THE ADDRESSES INDICATED ABOVE
FORM 13 (5-1999)
THIS NOT CE TO BE SENT TO THE PERSONS NAMED
BY FI L.
12/18/2003
SI(3NATUfiE & DATE Charlene E. ger,
Secretary