HomeMy WebLinkAboutMiscellaneous - 42 HIGH WOOD WAY 4/30/2018 (2) 42 HIGH WOOD WAY
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Safety Insurance
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner or Board of Health or
Inspector of Buildings Board of Selectman
City Hall City Hall
N ANDOVER, MA 01845 N ANDOVER, MA 01845
RE: Insured: JOHN A KLASHKA and FRANCES KLASHKA
Property Address: 42 HIGHWOOD WAY, N ANDOVER, MA
Policy Number: "HMA 0129250
Claim Number: BOS00032428
Date of Loss: 10/22/2012
Company: 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, 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 number.
Allan Leavitt Claim Examiner 10/26/2012
Safety Insurance Company
Homeowners Claims Unit
P. O. Box 55098
Boston, MA 02205-5098
Phone: (617) 951-0600 EXT 3213
Fax: (617) 531-8891
Email: AllanLeavitt@Safetylnsurance.com
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO D% O GASFITTIHC
(Print or Type)
l NORTH ANDOVER , Mass. Date /.; 93
bYW uilding Location �� 2 u10 b u/,q/ Permit
Owners Name
• New 71"4 Renovation D Replacement Plans SubmittedCk
FIXTUP-S
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IST FLOOR
2N0 FLOOR
3RD FLOOR
4TH FLOOR
STH FLOOR
6TH FLOOR
7TK FLOOR
STH FLOOR
(Print or Type) _ Check one: Certificate
Installing Company Name J� �yI�� J ; 0 Corp.
( 1 � �L 1
Address �� -��7A,i`�- 5 X Partner.
/�i�lf 5 .�� v� /`�• 03E--Firm/Co.
Business Telephone: K'Fz -1?M
Name of Licensed Plumber or Gas Fitter F
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy Other type of indemnity 0 Bond Ej
Insurance Waiver: 1 , the undersigned, have been made aware that the licensee of
this application does not have any one of the above three insurance coverages.
Signature of owner/agent of property Owner Agent
I hcreby certify that all of the dcuils and information 1 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 Weed for this application will be in compliance with all pertinent
provisions of tho Massachusetts State Gas Code and Chapter 142 of tho General Laws.
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By TYPE LICENSE:
Plumber
Title Gasfitter S'gnat o Licensed
City/Town:
Master Plumber or Gasfitter
Journeyman 9 i�z
APPROVED (OFFICE use ONLY) Lic se Number
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Date.. . .;`..� •
" 1304
NpRT#i TOWN OF NORTH ANDOVER
pf 4�.ao ,e,hp
r PERM1T-FOfi GAS INSTALLATION
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This certifies that . . . . . . . . . . . . . . . . . . . .I . . .
has permission for gas/installation,.
in the buildings of
at . . . . . . , ' f. 3f! 5<North Andover, Mass.
Fee. . . . . Lic No../�V.I . . .
5-78 ,-- GAS INSPECTOR
WHITE:Applicant CANAR Building Dept. PINK:Treasurer GOLD: File