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Aqw0wo—ol Safety Insurance
Fonn of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To- Building Commissioner or
Inspector of Buildings
City Hall
NORTH ANDOVER, MA 0 1845
RE: Insured:
Property Address:
Policy Number:
Claim Number:
Date of Loss:
Company:
Board of Health or
Board of Selectman
City Hall
NORTH ANDOVER, MA 0 1845
KEVIN SLATTERY and ANDREA SLATTERY
29 KARA DR, NORTH ANDOVER, MA
HMA 0243833
BOS00028397
12/15/2011
Safety Indemnity Insurance Company
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, Ch4pter 143, Section 6 to be
applicable. If any notice under Mass. Gen. Laws, Chpter 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 number.
Allan Leavitt Claim Examiner
Safety Insurance Company
Homeowners Claims Unit
P. 0. Box 55098
Boston, MA 02205-5098
Phone: (617) 951-0600 EXT 3213
Fax: (617) 531-8891
Email: AllanLeavitt@Safetylnsurance.com
1/13/2012
'ALTH
BOARD OF HE
Town of Norch Andover,Mass.
Date V i9F
13 IV4
Permit # o .. J—
APPLICATION FOR WELL & PUMP PERMIT
Application is hereby made for permit to drill a well (J. Application i�s
made to install (—) a pump system.
Location: Address ..Lot # . ......
Owner(,�'-, Address Tel.
D3
, — I 1T e 1 092- -W21.
Address 5�-4, , 1,
Well Contractor � , �qikn fi
Pump Contractor -,--�ddrcss Tel..
, ALM I-I-CZV -CaZT
WELL CONTRACTOR (To be completed at time of pump, test)
Type of Well A Well used for-j;�/71±t1by-j
-DiameLer of Well Size of. Casing_b
Depth of Bed Rock Depth casing into Bed Rock
Was Seal Tested? Yes No Date.of Testing
Well Ended in Wha.t. Material
Depth --o�&-W-e-�
Depth to Water Delivers. —1,5 Gals.Per Min. for. 4 hours
4 feet after pumping t GPM
Drawdown ;�—_hours- a
Date of Completion Wel
e Wel �Cont�rractor
PUMP INSTALLER (To b�- f-i-IIed in- before jilst.-illation)
S1 I ze & Name Pump Pump Type Used
-ink C
Water Pump Delivers C�_ (;pM Si;,,e of T
Pipe Material Used in Well: Cast Iron (,,aj,vnni.zcd Plastic (L�
Well Pit or Pitless.Adapt6r k
Was sleeve used to protect pipe? Yes (—) NO( f-4rype or Name Well Seal MV4"w-
- 11
%
D a t e
Date Water analysi'� r'ep6r-t �ubmicted to Board of u6al'th
Date release given tDowner of record & Kdg.. Insp
Health Inspector
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