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PO BOX 55098
Boston, MA 02205-508
617-951-0600
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
NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845
RE: Insured:
DAVID BARBATO and CHERYL BARBATO
Property Address:
740 SHARPNERS POND ROAD, NORTH ANDOVER, MA
Policy Number:
HMA 0319867
Claim Number:
BOS00052497
Date of Loss:
2/20/2015
Company:
Safety Property and Casualty 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.
Lindsey Hodgens Claim Examiner 3/2/2015
Safety Insurance Company
Homeowners Claims Unit
P. O. Box 55098
Boston, MA 02205-5098
Phone: (617)951-0600 EXT 3418
Fax: (617) 603-4914
Email: LindseyHodgens@Safetylnsurance.com
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
Ltninr...2e Mass. /Date 19% Permitk d�?
Building Location a%+%(� , (/�,a,r on r s Eo'd Owner's Name_(As.. /Z Ay" (orJ
Map: Lot: Zone: Type of Occupancy__FZe� r.
New 53 Renovation 0 Replacement .Cj� Plans Submitted: Yes Z1 No ZI
Fee:
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Ins taltingCompany Name EASTERN PROPANE GAS INC
Address 131 WATER STREET DANVERS MA 01923
Estimate Value of Work:
Check one:
Corporation
Partnership
Business Telephone (508) 774-19308g ] Firm/Co.
Name of Licensed Plumber or Gas Fitte�rT dl u-f'�tti
Certificate
INSURANCE COVERAGE:
have a current liability insurance policy or its substantial egviva'ent which mets the requirements of MGL Ch. 1�2.
Yes)a No -1
If you have checked yes, please irdicate the type coverage by checking the appropriate box.
A liability insurance policy N
Other type of indemnity ZI
Bond 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not haGe-the irsurznce•coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Ownafs Agent Owner O Agent
I hereby certify that all of the details and information I have submitted (or entered) in above ap kation are true and accurate to the best of
my knowledge and that all plumbing work and installations performed under the permit issu r this apptica ' will be in compliance withalt pertinent provisions of the Massac'tusers Sale Gas Code and Chapter 142 of the al Laws 1111
a,
Type of License: a *�,•�'" "
tjWourr,-iy!.-.an
lumber Signature of Licensed Plumber or Gas Finer
rite asrit;er _
as;er License Nurnber
City /Town
APPROVED (OFFICE USE ONLY)
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TO 2497 Date J� s�'11.�s? . .......
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TOWN OF NORTH ANDOVER g
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PERMIT FOR GAS INSTALLATION
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This certifies that .......... o
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has permission for gas installation ... PA 4!14 f ...............�.
in the buildings of .. 1q. r!�.. , :.t. 6. 'F4 `'..............
at .7 �/4 . S %? !,l? .'/'......... North Andover, Mass.
Fee. ?r:... Lic. No '/ .�..... ..........................
GAS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File