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HomeMy WebLinkAboutMiscellaneous - 71 MARBLEHEAD STREET 4/30/2018Date. 9531 � TOWN OF NORTH ANDOVER ., 1.°°c PERMIT FOR PLUMBING Thiscert f s that f� ....... has permission to perform . . plumb in the b`ui/ldings of ... `....j! ................... 1e 4 at .................... rth Andover, Mass. Fee '' .. Lic. No.. Zf/3S3 ..... ...... . PLUMBING INSPECTOR Check MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK f CITY _ a/� MA DATE �-�—Z— PERMIT # JOBSITE ADDRESS �✓ OWNER'S NAME _ P OWNER ADDRESS ®-'� e C TEL t7 Ax f TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL RESIDENTIAL ®� PRINT CLEARLY NEW: ®! RENOVATION: ® REPLACEMENT: ® PLANS SUBMITTED: YES ® NOQ FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE�I DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM E -__,_ _ ( !-.._.._-__._► _ _._.__._._.1 . _._.J _ _ _I _N_____ _ _. _._-_.._I :..._.._.� __..__._.J ( f _ _( DEDICATED GREASE SYSTEM _.711 _ l .__-_.-_._-i __....._...-! .-_-.-_� [ � _------_J DEDICATED GRAY WATER SYSTEM ( ....__( (._ _I ___._....._I _ 1 __.. _ I (. _ k J f _( DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER__-__ FLOOR/AREA DRAIN INTERCEPTOR (INTERIOR) _-JE. KITCHEN SINK -___.._._E LAVATORY ROOF DRAIN SHOWER STALL__._._i SERVICE / MOP SINK - (--___._1 I .---_.-.J ___�_I .______I _ _.__f ____,._i ._____f -_�_! _.._ (-__. __► ..__...__( _-...__� TOILET URINAL ._...-__ r E-7-71 WASHING MACHINE CONNECTION.._' WATER HEATER ALL TYPES WATER PIPING J, OTHER 14 e . li ' --_� See- _ _ _j INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO �] IF YOU CHECKED YES, PLEASE INDICATE THE T OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY - 3 OTHER TYPE OF INDEMNITY Q BOND M OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT 10 SIGNATURE OF OWNER OR AGENT t! hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowle and that all plumbing work and installations performed under the permit issued for this application will be in com ith all Pertinent rovision of Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME i ;,-?- C LICENSE # _q . - S G ATURE MP JP CORPORATION Q# ( PARTNERSHIP O# _ LLC Uj COMPANY NAME �•� G'L / d a !`�" 'd",t� !ADDRESS CITY C_ STATE ZIP TELz! 5t . FAX CELL I! I EMAIL z z o H U W a w \\ � Q� r z C] W � w O a z LLJ 3 U) I U) W a O > W � W 3 co 0 0 oa, a w � J a a a C -El w w I --LL. H O z O H U W P, a ' a I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UT www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name City/State/Zip: Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I eployees (full and/or part-time).` have hired the sub -contractors 2. am a sole proprietor or partner- listed on the attached sheet ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. [:1 Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit anew affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP. WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certlo un er ains and penaltde Perjurythat tl -information provided above is true and correct. Sienature: �i/.-'�'�/..�� late. Official use only. Do not write in this area, to be completed by c4 or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone V. I Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, • express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not producedacceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Comnoonwoalth of Massachusetts Department ofzndustrial .Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 Tel, # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 c ww—mtass,gov/dia Location` �o. — Date TOWN OF NORTH ANDOVER -. -- Certificate of Occupancy $ 1'�s'••E<� Building/Frame Permit Fee $ SACMus Foundation Permit Fee $ Other Permit Fee Tv TOTAL Check # j 1841-6 / Building Ins6eecctto( TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATF OR DEMOyLIISHH ONE OR TWO FAMILY DWELLING •A BUILDING PERMIT NUMBER: f `� DATE ISSUED: C;� 1 SIGNATURE: Building Commissioner/I —tor of 1 u Odin Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: / /I Map Number Parcel Number 1.3 Zoning Information:X 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R red Provided Re 'red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT HistoricDistrict: Yes No 2.1 Owner of Record ;% % Ile z� Ste, Name (Print) Address for Service: Signatdre`� Telephone 2.2 Oe}ner of Record: w Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Ni Applicabl _1 Licensed Construction Supervisor: License Number ee A(14 — Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone V M M ic z O rn O z M 0 ic r M r r s z Q SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 S 2.5c(61 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 .......0 No ....... 0 SECTION 5 Description of Proposed Work check all a ticable New Construction ❑ Existing Building Repair(s) 0 Alterations(s) ❑ Addition 0 Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: Ua / A SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to Completed by permit applicant L( s M" I . Building '-t i W (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) 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, as Owner/Authorized Agent of subject property Hereby authorize to act on My behal � 'n, -matt ela ' o wo by this building permit application. 57 Signature of Owner Da _SECTION N�7b OWNER/AUTHORIZED AGENT DECLARATION 1> C -1� I �' I ,' `7 P r 7' S� /y� 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 C% 1 A (Z-1/ /-I- Print Name Sig2atu7e—of wner/A ent Date �— NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR M4BERS 1 2 N15 3 SPAN DIMENSIONS OF SILLS DINIENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CBDANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE -f, M D. Robert Nicetta, Building Commissioner Please print DATE: 7 �� TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 400 Osgood Street North Andover, Massachusetts 01845 HOMEOWNER LICENSE EXEMPTION Telephone (978) 688-95454 Fax (978)688-9542 JOB LOCATION: 7IG �d S Number Street Address Map/Lot HOMEOWNER lipef Nam6 Home Phone Work Phone PRESENT MAILING ADDRESS `?/ /f1G �,,v`/ter, c,/ 5/ 2 arm City Town State N Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings to 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 HOMEOWNER 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 structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliances 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 North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. _ /r HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL BOARD OF APPEALS 688-9541 CONSERVATION 588-9530 HE', ALTH 688-9540 PLANNING 688-9535 m m m m VI m mm C O N C', m T m Cn cn 5 � v � R d � � xo y 'v p � S� :5�. o �S° tom'' p � o �- 'ti r 2 CA o � :r � o x o a. 0. C7 �• S CA C7 CD O '� O Z CACD R CLO ice !^^ CZE y d e"f CD cn CD o Q ww�,, = CD r� CD O CD O CD y CD. cn av y to CD O CCD CCD b Csf �i 7d C O N C', m T m Cn cn 5 � cnCA 45 � ° � R d � � xo p � S� :5�. o �S° tom'' p � o �- 'ti r 2 CA o � :r � o x o a. 0. C7 �• °� dCA �J W) M 1 s 0 P=h 0 c 0 a Date.%/...'f ' .--./ ..... . 3?p` .ao ,aa tip` TOWN OF NORTH ANDOVER • - PERMIT FOR GAS INSTALLATION 09 . . y �9SSACNUSEA i This certifies that .............. has permission for gas installation in the buildings of ... .� �' ` �.` �........................... at ... .... , North Andover, Mass. Fee.,/)-.-.. Lic. No...7./.,1. 3... ..... ..... . r GAS INSPECTOR Check # 3022 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING a (Print or Type) ))7,'., I, �u mass. Date -2661 Permit # G Building Location VO,/j Owner's Name /�10 s Type of Occupancy fa /CL - New ❑ Renovation ❑ Replacement Plans Submitted: Yes ❑ No ❑ FIXTURES Installing Company ,dame GLIMATE DESIGN Address Haverhill, MA 01830 (978) 372-9999 Business Telephone Lic. Plumber: Michael H. House Name of Licensed Plumber or Gas Fitter Check one: Certificate `'"Corporation / 9 /-13 Cv = Partnership = irm/Co. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of ,MGL Ch. 142. Yes i✓ No t -- If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy C Other type of indemnity G Bond O OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: Owner Agent C I hereby certify that all of the details and information I have submitted for entered) in the above application are and installations performed under the permit issued for this application will be in compliance with all pertinent provisions true and accurate to the best of my knowledge and that all plumbing work of the Massachusetts State Gas Code and Chapter 142 of the General Laws. • By Title ,peri License: PI mber = asiiner aster q % Signature f Licensed Plum r or Gas i r City/Town APPROVED tOFACE USE ONLY) �— Inurneyman License N mber BASEMENT MOM 0 �n■u■■u■n■n■ OMEN MEN MOMENIMMUMMEMME 4th FLOOR SEEMS MIMME MMOMMEMMIN 5th FLOOR NNE MEMEMMEME MOMMIN NNE 6th FLOOR— mom NJ —MEMEMOMMEMMEMMOMMEM Installing Company ,dame GLIMATE DESIGN Address Haverhill, MA 01830 (978) 372-9999 Business Telephone Lic. Plumber: Michael H. House Name of Licensed Plumber or Gas Fitter Check one: Certificate `'"Corporation / 9 /-13 Cv = Partnership = irm/Co. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of ,MGL Ch. 142. Yes i✓ No t -- If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy C Other type of indemnity G Bond O OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: Owner Agent C I hereby certify that all of the details and information I have submitted for entered) in the above application are and installations performed under the permit issued for this application will be in compliance with all pertinent provisions true and accurate to the best of my knowledge and that all plumbing work of the Massachusetts State Gas Code and Chapter 142 of the General Laws. • By Title ,peri License: PI mber = asiiner aster q % Signature f Licensed Plum r or Gas i r City/Town APPROVED tOFACE USE ONLY) �— Inurneyman License N mber m m m r- I T m I I D m O C I c c I i I I � I � I I I I m m m r- ,,OR 7M f � 9 ,SSACMUSE� Date. /� .! � TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that Pq,; ? y .`.t ... . ............ . has permission to perform ... :>.'. G. e.(.1 ........................ plumbing in the buildings of ...�.U:. c C, i, at ...?. �.�` !'.�f r.��... �........... ,North Andover, Mass. Fee...Lie. No.... . ......... . f .. tet ........... PLUMBING INSPECTOR Check # 5027 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) `?! Mass. Date /0.)j— tt 2W «Permlt # 4 IN Building Location �� �'IQ�� . /1(i( J J Owner's` ame�C�a��J(Jl/,'���L/ Type of Occupancy Af NV/W New Renovation V Replacement FIXTURES Plans Submitted: Yes No ❑ Installing Company Name Address 7 :R4Pwari S+rapt Haverhill, MA 01830 k Business Telephone Lic. Piumber: Michael H. House Name of Licensed Plumber Check one: Certificate �rporation l i %3 Partnership INSURANCE CQ-VERAGE: I have a clabilit urve y insurance policy or its substantial equivalent which meets the requirements of MGL Ch. i42. Yes Vo u If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy ❑ Other type of indemnity F— Bond C OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner - Agent u Signature or Owner or Owner's Agent I herebv cenifv that all of the details .ind imormauon I have submitted for entered) to the above aupiication are true and accurat to tb best or my knowledge and that all plumbing, work and muallauons oenormeu under the perms usuea for this application will be in compliance .vnh fill 'r mens orovision i t usens gate Plumbing Cixte and chapter 142 of the General Laws. By Signature or Licensed Plumber Tide Type of License: ?.tasters tkl"' > n lournevman L: GmTown License Number I l� .APPROVED iOFFICE USE ONLY) z Z z O x < V H N Z = V of OC OC Q Z V1 1•� W ��. t.,: ad H Q Q Z? Z H U m Z G Z cc O D W �. 4 a y Q„ Z owe a 0 W H< Y W W < H i F tIf to N ~' Z a O Z Z W W < Q V W y `- 3 Y 5 3 m o SUB-BSMT. BASEMENT 1st FLOOR 2nd FLOOR 3rd FLOOR 4th FLOOR 5th FLOOR 6th FLOOR 7th FLOOR ath FLOOR Installing Company Name Address 7 :R4Pwari S+rapt Haverhill, MA 01830 k Business Telephone Lic. Piumber: Michael H. House Name of Licensed Plumber Check one: Certificate �rporation l i %3 Partnership INSURANCE CQ-VERAGE: I have a clabilit urve y insurance policy or its substantial equivalent which meets the requirements of MGL Ch. i42. Yes Vo u If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy ❑ Other type of indemnity F— Bond C OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner - Agent u Signature or Owner or Owner's Agent I herebv cenifv that all of the details .ind imormauon I have submitted for entered) to the above aupiication are true and accurat to tb best or my knowledge and that all plumbing, work and muallauons oenormeu under the perms usuea for this application will be in compliance .vnh fill 'r mens orovision i t usens gate Plumbing Cixte and chapter 142 of the General Laws. By Signature or Licensed Plumber Tide Type of License: ?.tasters tkl"' > n lournevman L: GmTown License Number I l� .APPROVED iOFFICE USE ONLY) W W u. W U H W Y H z O cm I C 0 z W m 0 m z 0 0 2 O 0 z -4 0' m g> -4 0 o D m r rm 0 0 ri P4 r r c c c I)o 30 z n -4 X x 2. 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V J CO Ocn t0 o o�..�y m : N C a H: Q1 y.� cr // ^� C VJCL J CA r ^ .-►IE 4D Z— N ca :70 M ca to m OO ...► n �O ? /z� O m0 �G CD � CIA"• CD cn `° CD p O? . �` 7 rL d d rZ oa C. o M OMI 0 0 c z �, � r Z M o x Ccp W z x o r M OMI 0 0 c Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings North Andover, MA 01845 RE: Insured: Property Address Policy Number: Date/Cause of Loss: File or Claim Number: Daniel Bergstrom 71 Marblehead Street HP2414007 3/10/2005, Fire Damage 14379-W Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 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. Wade Anderson 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. Signature and Date ANDERSON ADJUSTMENT CO., INC. 54 Stiles Road, C-106 Salem, NH 03079 RECEIVED APR 0 4 2005 BUILDING DEPT.