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-