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HomeMy WebLinkAboutMiscellaneous - 75 PHILLIPS COMMON 4/30/2018o - 0 v M Q � O r O N w cp n o K P K 0 o z .r-..:: ....,-� .«�^+-'^=.r�s.rl i-i'ir..L.+moi -=..r ',.-�fi•x�.--.y...�-....-� .�. v _. _ _ S 1 t �� 15 1 Date..........;..................................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION \soo »<:c5'�A �/�� qy OWE v It V _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITMA DATE » Z.o _ PERMIT # JOBSITE ADDRESS S C - OWNER'S NAME GOWNER ADDRESS k. TEL! a I% ZO I LIOZ FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL CLEARLY NEW: ® RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO [ APPLIANCES Z FLOORS— BSM 1 2 3 4 5 6 7 8 9 1 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER 4VATER HEATER OTHER INSURANCE COVERAGE I have a current IIabiIijy insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ® OTHER TYPE INDEMNITY ❑ BOND ❑ 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 ONL . OW R ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are rue an accur to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co lianc ' all Pertinent of the provision Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME �eo\nq,r� Cj°�htl Y� A LICENSE # �Zc1 SIGNATURE MP ® MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION ® # Z? 6 3 PARTNERSHIP1 ❑ # LLC ❑ # COMPANY NAMEDrC'( XX-)tg6n,t%\ SgLryoCes `v,C ADDRESS -)s, \j3 CITY �-- r, C r, STATE ZIP C� 2�S S TEL,110 I '�S 6 FAX CELL"C>1 �o''I °1 M 7 ( EMAIL �/�� qy OWE v It V _ O Z F U w, z_ J Q z � O >- E s� � ~ V � w O F a W ft Z 3 AW I W Z Q uj > a O w cz w Q W (n .a V zz 0. a :� aU E.. a IL a I'll T Lii LL cc F O z 0 U a. z Q u 0 I t.. The Commonwealth of Massachusetts Department of Industrial Accidents t l Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): �1.7 �,, �rn�� �e,Y, IC,Q. tlC. Address: ` �V Q `\ 0.� c-sn City/State/Zip: �® T"� C A n 0_,�6 j phone #: � Are you an employer? Check the appropriate box: 1. ®, I am a employer with � ® 4. ❑ I am a general contractor and I �p 5 � � Type of project (required): employees (full and/or part-time).* have hired the sub -contractors 6. ❑ New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have g, ❑ Demolition working for me in any capacity. [No workers' comp. insurance employees and have workers' comp. insurance.+ 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 1 I.❑ Plumbing repairs or additions myself. [No workers' comp. insurance required.] t right of exemption per MGL c. 152, § 1(4), and we have no 12.❑ Roof repairs employees. [No workers' ® ^S 13. Other comp. insurance reauired.l *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Al \ t Policy # or Self -ins. Lic. A� 1�1 5-") 6 !� G p q 6 S Expiration Date: 1O Job Site Address X�l t 5. C�rr1 m pH City/State/Zip:n , Ay, to 9--t— Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under 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. 1 do hereby certfy under the try and penalties of perjury that the information provided above is true and correct \A2oI 't - Official use only. Do not write in this area, to be completed by city 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 #: ACORDy CERTIFICATE OF LIABILITY INSURANCE -DATE (MMIDDIYYYY) 9/29/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED 'PRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. ...,JORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Alliant Insurance Services, Inc. 40 Stanford Dr, 2nd FI Farmington CT 06032 CONTACT NAME: Brenda DlBattisto PHONE860-269-2157 FAX 86 o- EXfr _ _ A/C. No 0-284-0003 V,M 6S: bdibattisto@alliant.com INSURERS AFFORDING COVERAGE NAIC (t INSURERA:Zurich American Insurance Company 16535 INSURED GEM Plumbing & Heating Co., Inc. 1 Wellington Road Lincoln, RI 02865 INSURER B :Staff Indemnity & Liabili Company '38318 INSURER C INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 391568640 REVISION NUMBER THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ----- INSR LTR TYPE OF INSURANCE INSD WV0 POLICY NUMBERMMI DY EFF i tPOLII CY EXPNYYY) — LIMITS A X COMMERCIAL GENERAL LIABILITY GLO654159205 10/1/2015 1011/2016 .' EACH OCCURRENCE 1 $1,000,000 -- CLAIMS -MADE X OCCUR I DAMAGE TO R NTED PREMISES (Ea occurrence) - $300,000 MED EXP (Any one person) $10,000 PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 PRO - POLICY X POLICY LOC PRODUCTS - COMP/OP AGG $2,000.000 OTHER: $ 9UTOMOBILE LIABILITY BAP654159105 10/1/2015 10/1/2016 COMBINED SINGLE LIMIT$ (Ea accident) 1,000,000 X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ _ _ X HIRED AUTOS X AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ --- (Per accident) $ B X UMBRELLA LIAB X OCCUR 1000022112 10/1/2015 10/1/2016 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS -MADE AGGREGATE $5,000.000 DED X RETENTION $ 0 S A WORKERS COMPENSATION WC596960005 10/1/2015 1011/2016 X AND EMPLOYERS' LIABILITY YIN SPER TATUTE ETH - ANY PRO PRI ETORlPARTNER EXECUTIVE OFFICEPUMEMBER EXCLUDED"' a NIA E.L. EACH ACCIDENT $1,000.000 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $1,000.000 /(yes. describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Evidence of Insurance Coverage. CERTIFICATE HOLDER CANCELLATION �Oc 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) Thp ArORn namp anri Innn aro ranictararl marlrc of nrnan SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE �� �Oc 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) Thp ArORn namp anri Innn aro ranictararl marlrc of nrnan lJ BvaRQ �. PLUM9ERS�t€� GASF {T E€25 LSS,EJES .THE ';EOLLQWlNG L'lCENSE DATE: LOCATION: OWNERS NAME: GENERATOR kw V-) 1C CONTRACTOR: G z- N-> 1Q,c�naY,�c.a�'TQY-s)%ceS PHONENUMBER: a6--) 'ELECTRICAL `(RESIDENTIAL COMMERCIAL TEMPORARY LOCATION OF GENERATOR: *ZONING DISTRICT: K3 fl -D *PLANNING APPROVAL (I )t *CONSERVATION APPROVALS, vlo U Location� No. DateZ— N°RTIy TOWN OF NORTH ANDOVER Ot,t�1O ;x,'40 3Z i OL p Certificate of Occupancy $ 0 0 0 Building/Frame Permit Fee $ /�� ✓ o Foundation Permit Fee $ Sf MUgE Other Permit Fee $ ® wer Connection Fee $ *q Tarte nection Fee $ IVO 19"� ,d 10 1% ` Building Inspector Div. Public Works Location' -7:5 No. / I I Date TOWN OF NORTH ANDOVER ertificate of Occupancy $ uilding/Frame Permit Fee $ Dundation Permit Fee ther Permit Fee OMTnection Fee MAVP2180b Connection Fee TOTAL " No. Andover Collector (Buit'ding Inspector Div. Public Works PE&JIITfO. l / APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP K40. LOT NO. Cf 2 RECORD OF OWNERSHIP 'DATE BOOK 'PAGE ZONE �� SUB DIV. LOT NO. Uoe -LOCATI N ^, f A PURPOSE OF BUILDING } ; OWNER'S NAME�V\twl1X�_\orr��r.�-\t�-r AM�nn 1 NO. OF STORIES `1 i IZE ii Z OWNER'S ADDRESS I F i V SEMENT R SLAB ARCHITECT'S NAME C SIZE OF FLOOR TIMBERS IST !7„ 2ND f) x� 3RD BUILDER'S NAIVEII'+ 110 Lk C£ ` SPAN I (l 1 _ DIMENSIONS OF DISTANCE TO NEAREST BUILDING "'( ( I.O 1 DISTANCE FROM STREET I POSTS, 1 DISTANCE FROM LOT LINES - SIDES ^ ,.)I Oi-C REAR ;to1 GIRDERS 5y ) 1 AREA OF LOT I I G�� �� J1 FRONTAGE I 00 HEIGHT OF FOUNDATION C'•,�1 THICKNESS 'G t/ IS BUILDING NEW , �� vl SIZE OF FOOTING 1 ZL I X IS BUILDING ADDITION l 9 O +� MATERIAL OF CHIMNEY IS BUILDING ALTERATION )v O IS BUILDING ON ID FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE l:> IS BUILDING CONNECTED TO TOWN WATER N BOARD OF APPEALS ACTION. IF ANY ! \ N IS BUILDING CONNECTED TO TOWN SEWER fa� IS BUILDING CONNECTED TO -NATURAL GAS LINE` QS INSTRUCTIONS SEE BOTH SIDES PERMIT FOR FRAME/BUILDIP PAGE 1 FILL OUT SECTIONS 1 - 3 2,7-/22-- { L PAGE 2 FILL OUT SECTIONS 1 - 12 DATE:dFEE PAID//& ELEAC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHEb GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED .51 FEE PERMIT 19 PERMIT FOR FOUNDATION ONLY REGULATED BY PARA 114.8-S. B.C. DATE 2" z FEE PAID _ w0 a OWNER TEL. # (0 6 CONTR. TEL. #a CONTR. LIC. # 17 I BLDG. PERIViIT FEE. LESS SDA FEE / 00 DUE FRAME PERMIT $-I-LL L, 4 3 PROPERTY INFORMATION LAND COST D 06 LIEST. BLDG. COST EST. BLDG. COST PER SQ. FT. ST. BLDG. COST PER ROOM 42 - SEPTIC PERMIT NO. ' 1 r4 V 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN KA ov�w�pv .r�er6f.:1 f7R N 1' BUILDING RECORD 1 OCCUPANCY 12 2 SINGLE FAMILY I STORIES +. � � ` MULTI. FAMILY r OFFICES 1THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM -_ LOQ LINES -AND ,.,EXACT• DIMENSIONS.' O'F•,'. BUILDINGS. -WITH PORCHES. GA - APARTMENTS RAGES, ETq. SUPERIMPO§E,6 THIS REPLACES PLOT PLAN,. CONSTRUCTION _ 2 FOUNDATION 8 INTERIOR FINISH CONCRETE B I 2 I3 CONCRETE BL K. PINE BRICK OR STONE HARDW'D PIERS PLASTER x DRY WALL 1I 'J '� 1 UNFIN. .-. 3 BASEMENT, 1 ? v 1 AREA FULL FIN. B'M'TARE,4 1/1 1/2 1/1 FIN. ATTIC AREA NO B M FIRE PLACES ---f _•' • :,_ .._ , HEAD ROOM _ MQDERN KITCHEN 4 WALLS 9'•,.; FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES .1ARTH HARDW'D COM/JCN ,ASPH. TILE --� ; _ _ I i l HEATING ASPHALT SIDING ASBESTOS SIDING_ VERT. -SIDING PIPELESS FURNACE STUCCO ON MASONRY\ -, STUCCO ON FRAME FORCED HOT AIR IF BRICK ON MASONRY r'.,;i 1 BRICK ON FRA -M1 `y. A4fIC STIRS. & FLOOR _ CONC. OR 10415ER 61K. WIRING STONE QN.MASONRY •. STONE O F AME' " SUPERIOR POOR _ ADEQUATE I NONE • 5 ROOF 10 PLUMBING GABLE HIP BATH 13 FIX.) GAMBREL MANSARD TOILET RM. 12 FIX.) FLAT SHED WATER CLOSET ASPHALT SHINGLES LAVATORY _ WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING TAR & GRAVEL STALL SHOWER _ ROLL ROOFING ' MODERN FIXTURES TILE FLOOR TILE DADO --� ; 6 FRAMING I i l HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR IF TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT' H'T'G UNIT HEATERS p #R !g� 7 NO. OF ROOMS GL OA� �� � } L_ B'M'T 2nd ELECTRIC 1st �1 13rd I NO HEATING +..-.-.-- -- I E'•� ..� 'Z.' YA110 VIOITA1111071 R-1011 P71317314 i YA110 VIOITA1111071 R-1011 P71317314 FORk1 U TOWN OF NORTH ANDOVER LOT RELEASE FORki SUBDIVISION ASSESSORS MAP SUBDIVISION LOT(S) /—©f PERMAN� T A RESS ASSIGNED BY D.P.W. _��� STREET S �CJy� APPLICANT OCW41V21 De,y PHONE DATE OF APPLICATION TOWN USE BELOW THIS LINE PLANNING_BOARD TOWN PLANN CONSERVATION COMISSION DATE APPROVED r 'q7 DATE REJECTED DATE APPROVED llATE REJECTED �� v"- G5�e DEPARTMENT OF PUBLIC WORKS APPROVED MAIL. REJECTEll DRIVEWAY PERMIT 6a c SEWER/WATER CONNECTIONS ,tt,c. FIRE DEPT. (J,ri S RECEIVED BY BUILDING INSPECTION DATE This form shall be signed by the agents of the Planning and Health Boards, the Conservation Commission prior to the issuance of any building permits for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. All,TE," /�tiiV0.4T/O�/ LSCA>/ON �Scie✓EY, c -•� X9.5 �' I 32. 4. Exisri,,/G �O✓NbR7/ON MAY 1 91992 i t s .�✓EREBY CECT/FY TO 7We 2-174E 1A1S&WO.P ANO �L or R4 41t/ TO 71-16* BA.Ve Ts1gT T1/E 0w6L4 lvG /S LOC.4TE0 67A/ T1/E Lor .fs S/,dirN ANO 71d4T 1T OaES L'O.f/FcolleW /N IY/711 T11E 7V--1OFA A.voa✓�,� ZON/NC PEG!/LAT1eA1s , / REGA,PD/N!, ,SETBAC.t'S FROM If LOT el vES 0 1 F(/.rrHEP LEP T 7//1-f oM'ELL1N6 /S NOT l L/lGgrE.O /N T 000 .5�.4ZA.P0 A.PE.a. - O.PAi✓iV FO.P &fdtVAI 0/t1 /Ty /olNGG o� y v��/icG1PS �Q7iino,✓ �E✓Eca.�irlE.vT �oFP JEFFREY �asao98 oaoSB S. NN TO. 0.4TEj� J F 638 S. OTE N� SURV� rv. TiS//S 1111Z,41V iFO,(� 0,P7GgGE PaPPOSES - it/OT FOP Bovvopsi oErE.P�sirl.9riov_ .00/%vo�.ey iti.�o.P�- /1lE.P.P/�1.9G� �,vGir/EE,P�.t�G SE.PI�/CEs .47'/041 r,4.rE.y ,�,�-o,H Exrsr�uc PE-co,Pos. 6� f'q•P,(� ST.PEET A.t/00YE.P, /W-5S4I.%//SETTS O/8/O co ¢LLJ �.Sca S y � J m W m iL OO H W Q., O U a A 1 aom W � O o CL u E : d v .�. .� C O C to Z 0�, Q m 0 CIO U �J c ._ :r. _ 0 0 0 0 oC 0 W d O. W CV f. IA IA IA z z z W W o c uh z �_ o z ? m N � W m L C J L m ` W 0 t C O C O m C O - 7 E ¢ v ii C` ii CC cn U. Cz m m S y � J m W m iL OO H W Q., O U a A 1 aom W � O o CL u E : d v .�. .� C O C to Z 0�, Q m 0 CIO U �J c ._ a aLL �O z 2 t«. CD z 0 m W Q 1�- Ll— LLS 91. .Q 00 C M r,S V to .a I --M-1 m c 0. +"' w IVJ ��l H Z •'� ZQi —0 ? W W m D H u M. j—,v j a�� \ LU 3` p m C OO cc co t«. CD z 0 m W Q 1�- Ll— LLS 91. .Q 00 C M r,S V to .a I --M-1 m c 0. +"' w IVJ ��l I~ O 0 U N a •r -I a rn O a F- M Y g s 0 C6 Qs • r L .q s 4 • m C6 Q' • C • • • t `� N I of 0_ c 0 x� J Z = N)P ( W L N a o W �J 0 0 O Oro� ° �i 2 ow � �L J . #$ 44 2m m ° : C.7 U, =M. N n+ 1 Q V .Z O Id LL O U U uj N g Jo s 11a LL Von* D— Q IL ~ LLJ IL W� CL - 0 I- �--� W a r W !0 I~ O 0 U N a •r -I a rn O a F- M Y g s 0 C6 Qs • r L .q s 4 • m C6 Q' • C • • • t `� N I of 0_ c 0 x� J 0 a 0 E 3 z IL O C 32 p� t-2 I r i 0 Ilk i I Insurance Adjustment Service, Inc. 139 Billerica Road, Unit A-1 Chelmsford, MA 01824 (978) 256-3334 Fax (978) 256-3354 UNDER MASSACHUSETTS GENERAL LAWS CHAPTER 139 SECTION 3B TO: Board of Health/Building Inspector RE: Insured: Aiguo Yan & Xiong Wei Property Address: 75 Phillips Common No Andover, MA 01845 Date of Loss: 4/16/2007 Ins. Claim Number: 10003060MLG Date: April 22, 2007 RECEIVED APR 2 6 2007 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Type of Loss: Strong winds and wind -driven rain caused damage to bedrooms and fence. File or Claim Number: 40576-tm 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, Ch. 139, Sec. 38 is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, locations, policy number, date of loss and claim or file number. Thank you for your cooperation. Very Truly yours, Tim Martino Adjuster Ext. 135