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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
NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845
i
RE: Insured: PAUL LAMM
Property Address: 755 JOHNSON STREET, NORTH ANDOVER, MA
Policy Number: HMA 0011681
Claim Number: BOS00044271
Date of Loss: 7/17/2014
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, Chgpter 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.
Bryan Savosik Claim Examiner
Safety Insurance Company
Homeowners Claims Unit
P. 0. Box 55098
Boston, MA 02205-5098
Phone: (617) 951-0600 EXT 2070
Fax: `(617).535-5841
Email: BryanSavosik@SafetyInsurance.com
7/18/2014
IA
NORTH ANDOVER BUILDING DEPARTMENT
400 Osgood Street
Tel: 978-688-9545
Fax: 978-688-9542
BUSINESS FORM FOR TOWN CLERK
DATE: f l I U S
NAME:
ADDRESS: Sb T �� u i,\S T j�l v r7-1,, lin c� d �/,e a-
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ZONING DISTRICT:
TYPE OF BUSINESS: i✓1 w u �= w t� ✓�' R� Phi r wi i ✓y
BUILDING LAYOUT PROVIDED: YES NO
AVAILABLE PARKING SPACES: 4 N u
ZONING BY LAW USAGE: YES NO
BUILDING INSPECTOR SIGNATURE
Revived 11.5.04
BUSINESS FORM FOR TOWN CLERK