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MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston, Massachusetts 02108-1904
(617) 723.3800 Ma Only (800)392-6108, FAX (800)851-8424
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws, Ch.139, Sec.313
NORTH ANDOVER BUILDING COMMOSSIONER
NORTH ANDOVER TOWN HALL
NORTH ANDOVER MA 01845
Re: Insured: LUZ G. ROJAS, DANIEL ROJAS,
Property Address: 37 RIVERVIEW ST., NORTH ANDOVER, MA 01845
Policy Number: 1195204
Type Loss: Fire (including Fire caused by Lightning
Date of Loss: 0712412016
Claim Number: 407956
Claim has been made involving loss, damage or destruction of the above captioned property, which may either
exceed $1000.00 or cause Massachusetts General Laws, Chapter 143, section 6 to be applicable. If any
notice under Massachusetts General 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.
MPIUA Claims Division
CMA00021
712612016
TO:
RJS
ROBERT J. SWAJIAN & ASSOCIATES, INC.
INSURANCE ADJUSTERS
1820 TURNPIKE STREET — STE. 207
N. ANDOVER, MA 01845
TELEPHONE (978) 655-4994
FAX (978) 655-3571
Info(a)RJSAssodates.biz
FORM OF NOTICE OF CASUALTY LOSS
TO BUILDING
UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B
Building Commissioner or Board of Health or
Inspector of Buildings
Town Hall
North Andover, MA 01845 Same
RE: Our File No:
16-31052
Insured:
Luz G. Rojas
Loss Location:
37 Riverview Street
Date of Loss:
7/24/2016
Policy Number:
1195204
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, Chal2ter 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.
ADJUSTERS
TITLE:
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.
Robert J. Swajian
Adjuster
July 26, 2016
NA IQNAI
ASSOCNi1pN
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This certifies that ..... Lt . w yv
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Vin; , _ has permission to perform . '.. • .......... . .
-wiring in the building of
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at// orth Andover, Mass.
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r. ELECTRICAL INSPECTOR /
's
Check # 3
10923
Commonwealth of Massachusetts Official Use Only
2
Permit No. I a J
Department of Fire Services Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: G,-1? ^ i Z
City or Town of: To the inspector o NORTH ANDOVER P f Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 37 /Q6r�e.�— V e.� S
Telephone No.
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building $Ct+eJWfir! fear .o st"•4'fia M Utility Authorization No.
/ Volts Overhead ❑ Undgrd ❑ No. of Meters
Existing Service Amps
Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
No. of Recessed Luminaires
No. of Luminaire Outlets
No. of Luminaires
No. of Receptacle Outlets
No. of Switches
No. of Ranges
No. of Waste Disposers
No. of Dishwashers
No. of Dryers
Fater KW
Heaters
o. Hydromassage Bathtubs
Completion of the following table may be waived by the Inspector of Wires.
No of Total
No. of Ceil: Susp. (Paddle) Fans
No. of Hot Tubs
Swimming Pool grnd e ❑ grid. ❑
No. of Oil Burners
No. of Gas Burners
No. of Air Cond. "'
Total
Tons
HeatPump
Number
Tons.........
KW •.,.,
Totals:
Space/Area Heating KW
Heating Appliances
KW
No. of
No. of
Signs
Ballasts
No. of Motors
Total HP
Transformers KVA
Generators KVA
ALARMS INo. of Zones
o.
No. of Alerting Devices
No. of Self -Contained
El Municipal El Other
f nnnectinn
--Ro.of Devices or Equivalent
Data Wiring:
No. of Devices or
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) .
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: �'4a� I! C LIC. NO.:
Licensee: Signature LIC. NO.:
(If applicable, enter "exempt" in the license number line Bus. Tel. No.:
Address: 3 NOPE ��c De Public �Safety3 " Lid cense• Alt. Lic. No.
*Per M.G.L c. 147, s. 57-61, security work requiresDepartment
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
one) El ❑owner's agent.
required by law. By my signature below, I hereby waive this requirement. I am the (check
Owner/Agent Telephone'No. PERMIT FEE:
Signature
6,?3 4� s�
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