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HomeMy WebLinkAboutMiscellaneous - 77 SUGARCANE LANE 4/30/2018 (2)m 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: Edward and Catherine Shaw Property Address:77 Sugarcane Lane Policy Number: VX1764 Date/Cause of Loss: 10/17/2006, Rot Damage File or Claim Number: 16766-C 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. Chris Town 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 Commonwealth. of Massachusetts City/Town of System Pumping Record Form 4 qly DEP has provided this form for use by local Boards of Health.. The System Pumping Record must be submitted to the local Board of Health or other approving authority. . A. Facility Information Important: When fining out 1. System Location: forms on the computer, use only the tab key Address to move your cursor - do not City/Town use ttie;returnState Zip Code key. 2. System Owner. CS Name iL Address (if different from location) City/Town State e 6a Telephone Number B. Pumping Record <�' 1. Date of Pumping Date _ 2. Quantity` Pumped: canons 3. Type of system: ❑ Cesspool(s) Septic Tank- ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No 5. Condit io of System: i License Number Signature f 4 ler http://www. mass. gov/dep/water/approvals/ t5form4.doc• 06/03 Date Comm nwea I► of Mass husetts ll assachusetts System Pumping Record Systen► Owner SAV-/uj System Location 1-7 i - Date of Pumping: � -- Quantity Pumped: -1� gallons Cesspool: No Yes Septic Tank: No Yes System Pumped by: Fcu`edarf, License # Contents transferrred to : Greater Lawrence Sanitary District Date: OC i -41999 Inspector-