Loading...
HomeMy WebLinkAboutMiscellaneous - 94 SAUNDERS STREET 4/30/20184 Date ..... X 0 - TOWN OF NORTH ANDOVER 0 SP low, PERMIT FOR WIRING This certifies that .......... has permission to perform ............ ....... wiring in the building of .M.......... . ............................. at... ............ ...................... . North Andover, Mass. Fee----,UQ('t110Lic No S.�� .... ... AM, � —I A .......... ..... ELECTRICAL INSPECIO Check # Commonwealth of Massachusetts Official Use Only [ Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS1/99 1 Rev. � j ( leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed io accordance with the Massachusetts Electrical Code (MEC), 27 CM 12.00 (PLEASE PRINT IN INK O4negives E LL I FO IATIDN) Date: City o - Town of: /(,l t�-�f2, To the Inspe for Wires: By this application the undersi ii fice of his or,her intention (W)Grform the electrical work described below. Location (Street S N mber) Owner or Tenant Owner's Address 41 S Telephone No. "0 &3- 5-/6 Is this permit in conjunction with a build', permit?Yes ❑ No � (Check Appropriate Box) Purpose of Building in.J /ice tArri. tUtility Authorization No. 0 Existing Service &) Amps .i' / 2 ®Vo s Overhead Undgrd ❑ No. of Meters New Service Amps J` !�L/ molts Overhead Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �cT� t CCL I/C-el l GI Completion of lite follo„ vin, table mem be waived br the Inspector of lVirec. No. of Recessed Fixtures No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Above In- Swimming Pool rnd. ❑ crud. 1:1 No. o. o mergency Ig I Ing Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners of Detection and No. Initiating Devices No. of Ranges No. of Air Cond. Total. Tons No. (A Alerting Devices b No. of Waste Disposers Heat Pump Number I Tons I KVV No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑Other Connection No. of Dryers Heating Appliances g PP KW Security Systems: No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent Hydromassage H dromassae Bathtubs No.g No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Allach additional detail if desired, or as required br the Inspector of II'irr.c. INSURANCE COVERAGE: Unless waived by the owner, no permit for the perforniance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the perm%t istiui... otficc. CHECK ONE: INSURANCE F�eK B ND [IOTHER El (Specify:) nJ (Expir, n Da ) Estimated Value of ElectWork: `� (When required by municipal policy.) Work to Start: tib Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under re pa and p mai ' of-peJuly, that th ,inform 111011 on'tiris appl' ation is rrue and c•omlVete.�c FIRM NAM /vfiU /L /C`rs r� LIC. NO.: Licensee: vtl Signatur LIC. NO.: (If applicable el er ' e �em�p�i�'" ' t the I— nun ine.) �J� Bus. Tel. No.:C v f6� Address: �tiClotl/GfN> ty'�d. i eC� /�Q� Alt, Tel. No.: - e���� OWNER'S INSURANCE WAIVE 1 am aware that the Licensee does uot5u ve the liability insurance coveragC`rior`rlally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's aunt. Owner/Agent Signature Telephone No. PERMIT FEE: $ m a � IL r - N N rc W m f C 0 0 J LL J IN a 4 0 Z 0 m F j W W Q rc � W < N < Z 0 Z 0 m N W W W Z Z H < mN_ _N O O N W N N LL W 0 f z Q > z Y J \ z z o U 0 LL W 0 mo r< 0 J f 0 m G W h x o Z 0 N m Z .W! LL W r w O N J N W F U O z 0W G W z < < a o (y �0 'O cs`sET� ..... ciq oirn :.AG°� ads �� oc ti0 Cdr o .o o '� 4 < oo 0 z r 0 z z z o s8' i 1 ��D �% W _ a I AGu pmc ' I G a � P a rOi 4 0 N i N W _z J F 0 J f 0 C LL W U Z F N G J W N LL 1 0 f o Q > z W J \ z z o Q F 0 LL W 0 mo r< 0 J f 0 m G J J o 0 N F Z .W! LL W r w O N J N W U O J 0W G W z < < a b z 0 O O 0 p < Z Z Z J LL O O O O O m W m m m J < Ir 0 N N N 3 J a z 1 f o Q > W J \ y �q F Q F 0 LL W 0 J 0 J f 0 m G J J 0 N F u .W! LL W 0 0 N N G G W < d O b v •; V 8m3 mm Opt AtiN� �ADOvDDD D T OO NN(1m ~~OAACC ZZAxxnnJOmMO pDN Nm D N Oil A v A mZ� O• D m W o mA00 mnn z N D; N TrIZ -i prA m 0 p r m0�~mw pD mm ('1 O !•1 yDp O I °' D NflZ 7c mp A -a0 y -r m A D i N 3 O Aa 00 O N+ A = mm N 00000 Z Z A Z Z O O, O O O� N N N N D 2 A � O �» C p y m m m T �' z> y 1 H H G Z I T 3 =� > A> Z Z Z N O Z Z NO 3 O ti N O _ pap. N �'^ mZ N x A jDZDNp3G)pZoO pm O D N �n �r uDi O Z x Z C { o a w O n H O m=; N m D a O n m O Z A m Z 3 Z N r 3 Z y { { N ~ 00 n { Z O I_ Z ISI- _I I I I I I I I I I I I I I I I I I I I I I I I_ I I I -LI Z�^OGICADIyT� O r D Z �"' D p p O m O v r rti;AZA r r O D O 4 �-/m D D G O D ~ Dom' a m D y Dfl2 N O V D D A (1 O l0 � TT_T O A Z Z COv2vi Z A D Z M C ON O (l 2 ti N 1 D n G; T m m p T r (1 r T 2 y A y 2 Q m C� A n 2 S A 0 2 Z m p m D m T Z` '( N m p O m n T n x m A �n G p vOZ=�Zm m DO H ~�O y A? Zi+�' DAG z DyZ--1 > IN 0 OOT_ ;'_' ^+ y mZ ^' xmn-� p -Zi 0� A 1' O ~ A S A X` COm Z Z ON X r ` a T N >> (1 A z NO Z Aci D Z A n T 1 A T r A D A D A 1 I J_L I I I la O D p A X a O Z O A '0 M- Z Z I I - I I I I I Z LI I LJ_ I 1 I1 11111" m A I _ i III 1111 _LLI�I_I IIIIIIIW IIII � 0 0 D z n SON N NrN zm lm a0 yZZ °c �M DU) n 0'10 Ulv* p3m MX -I ZD I_N_fl N0 �z-1 - mN3 'aOZ -N m 0 Wsz F rr-o0 UZr ANO a a z�z I° vN MD oz In mm y0 3 C rr v_ z 0 m n O r v (Please print) DATE Z2� JOB LOCATION Town of North Andover BUILDING DEPARTMENT 0 Homeowner License Exemption umber Street Address Section of town "HOMEOWNER" I%� �.cJ.a,c� /%��,�, , /_ �_-P. c.,. -i/_ „ ame f dome rhone Work Phone PRESENT MAILING ADDRESS ,.2_�js S,-,, Glty/'Town State Zip code The current exemption for "homeowners" was extended to include owner occupied dwellings of six units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code, Section 109.1.1) DEFINITION OF HOMEOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one to six family dwell- ing, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Bulding Official, that he/she shall be responsible for all such work performed under the ,building permit. (Section 109.1.1) The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and ;'requirements and that he/she will comply with said procedures and requirements. -HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35,000 cubic feet, or larger, will be required to comply with State Building Code Section 127.0, Construction Control. 0 FORM U - IAT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or • landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: A14 " 4 1 1 4 e / ,_� 'Oe0,91 Phone LOCATION: Assessor's Map Number y Parcel 14 Subdivision t G+ Los) Street f �i Sn i 7)� � St. Number 9 ************************Official Use RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrat Date Approved OZ/ X7 9� or Date Refected Comments Town Planner Comments Health Agent Comments Public Works - sewer/water connections - driveway permit Fire Department Date Approved Date Rejected Date Approved Date Rejected Received by Building Inspector Date U 0 z til cc F - z W I OR o� n r• oe O lag 109 >% 0 .a Q c • — Q u H o O N O Z Or Q in 111 � c Z Z W W o p V IL L ° C Z a Z u y. ? ad Q � m ° W m o ._ — °om mm L C ..1 L d J W` L V L x O C C C C ` Cl U ii ii m co ii m ¢ ii cE cc F - z W I OR o� n r• IV 4) oc m >% 0 .a Q c • — a H N .�CL E Z Or Q in 111 � c c yr L ° a. u a E c y. c ° c c z ._ — °om V 0 IV 4) oc m >% 0 .a Q c • — N Z I Location No. Date ,&ORTM TOWN OF NORTH ANDOVER 3? Is ! 0 o p Certificate of Occupancy $ # �>_ Building/Frame Permit Fee $ • s • '► o��O�+ne 'A`�i . ,,,Et Foundation Permit Fee $ � Other Permit Fee $ QCf' q er Connection Fee $ N0. 41%, l 6 NPV� a onnection Fee $ do��rC TOTAL $ h 0/%i Building Inspector Div. Public Works rl a� <I a _ Y 0 0 m W r w (� a X N m mi W W Z Oc O z Z L D t 0 J J � W � _ m K O 0 0 0 0 Z W N (A ILW I d 0 w D N L Z m m 0 ►, IS S 0 Z U r � IO a 0 % Z � 0 m J N � r N N W � O N N W W 0 0 3 3 F N J 0 0 �a l z W L w 0 r Z 0 rc U. 0 Z 0 0 4 LL 0 w N_ i W Z 0 r 1 z � 1 W uri Z f I � M ( W Z z 1 (� O O 1 r � ! K W `,� V W ° W W z < vJ Z_ NI W W K 4_ 0 J J J 4 4 I 0 N Z W W W W 0 I Z f 0 N L L 1 rZ 4. 0 tr r r w J Z F 0< 0 z W ¢ 0 r C O J w J 3 ° r U < < zz w 0 0 Z<< L O y Z 0 4 w 0 0 0 ° < 0 J Z Z_ J 4 u W W W O _Z F W Z ZZ O J J J m O ° J U 0 N N W m m m < < N d! N 3 m z 0 f m 0 z } r 19 Wii L 0 lz L M m 01 ul O ' Zi r W 6 r � u AJ m m W W O z W L u E m N Z 0 r 1 � 1 1 uri Z f � M ( Z z 1 O O 1 r � ! W W W W r I r i W 0 0 J J x 4 4 I 0 N m W W W 0 0 I N L L 1 4. 1 LL I J I L 0 0 a S Ql 8m� N 1 000 y. . A -� Op y v p v p a D v; ; O O p z Oma T N �� y T D Zm (A O� as NO O Z i1 _ O a N __ IT�II TT (A N n()) p N V N < D �* O n m Z- D v_ w n n y 3 Ill OOZnnccmwvO0>4 rIO�mW A�OZ�N Dylz mmnx xnn ~N D O p� v>� > N 7C nn 00000 000y�tn0 A3: Omm m m Z Z A Z Z O O O N N S p 0 -1 C p m m w Z D y T np;ZZZL,LZZo 3 , O v �3 A pD 2>>-rOa 00 uDi O z O 3NpmmNDN ZZN << p y p m Z N = y n > > n;T_TT COa2T M 0<n O mm v;n nZ OomZZ T<NAZi (l) (= rp D D A n X S o= m p v y �> Z Cp n m z m p pj m Z O m e n A 01 '_° T 1 ILL O Z D D I^ I I I� Z 2 O Z A p Ll_IIL 1 1 1 1 1 lw I I I A II I�I II I" SON N yrN m Mmi n� aZ NZZ �v3 MX D� tl 0�0 U) p3m mx -4zD I (A Ul 0 0 �z_ mN3 D�tn C m�0 r - z v r r!20 Z Oar �N0 D*D m ?�z A Io O 0- v ID �z In mm N -q D3 1 y. . N O o N z O m N H N 2rAr v p. ..o m"O o O O ".0 > •;9 m o W �n�OD np0 I ( +pm = -qz ` W W N m - O► m 30 .00 000 2 m m V .� N S aG ,. zo30 m = m O a .O oo TZ H£m? ` li Camm. O- CP zoo >.C)Z r t Z 3 � Qi O F ;° mj`m AT O Nom ,i d O m 2 z 0 o o Z>70 C xl G! W 0 N O � rlIc ; m Oz >0 3r m on o n mTZ m` r m -60 p0 'm mrn Or C r�i *0 0 O < °' 0?5 a 00 ° Z M y m m T ✓ m > z M+ 3 C) z v c z O K " R1 _ -4 0 � � -n m m ° O D n mm S co Z Z 0 m m m = 0 17 m r* i ht m m O D O o �„� r Z �1 D m eti m 1 N 0 z> C W 0 3 C) z 2 -+ A DCl) ca m r m O Z D m opo m ? o m { m cn D O N m m -� m m C { � / / . S [� oNE G S(i)ASA tJ$oZxlo 'ICY 5r4 �/ o� r c' 414 ate,- --*s,a o w,S s . / d� �2ooiy Suggested Affidavit for Home Improvement Contractor Permit Application For Office Use Only NAME OF CITY/I'OWN Permit No. Date AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c.142A requires that the "reconstruction, alteration, renovation, repair, modernization, conversion, inprovement, removal, demolition. or construction of an addition to any pre-existing owner -occupied building containing at least one but not more than four dwelling units or to structures which are adiacent to such residence or building" be done by registered contractors, with certain exceptions, along with other requirements. Type of Work: 4tlrew e T ©N Est. Cost 000, 0 0 Address of Work / 7 i / G- lr �/� •��/rC cJ Owner Name: 0 A s.- C 'If S 7-L' Date of Permit Application: /Q/i 6 I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law _Job under 51,000 _Building not owner -occupied 3G Owner pulling own permit _Other (specify) Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. Signed under penalties of perjury: I hereby apply for a permit as the agent of the owner: to % 61�)-- /-*c,4ygc a S G S Date Contractor Name Registration No. OR: Notwithstanding the above noti e, IAreby apply for a permit as the owner of the above property: 0-16 -7 c` Date Owner Na a ov 1� r lw M I LR z r M 4 z O r �K c 01. or W T T fn n m 3 c o m o o so Pr ? n ? c C O TFM z + 4 z O r �K c 01. or M c O cc U O J 69 69 69 69 69 69 EA U a� m � O 7 c LL O O O cc L 4)U C = E O C Qj C c Li U O U U m Li p ¢Q RIO YNO.L i y 0 _Z O m J_ < ] W � m � LLO 0 0 r W N Z o IL L 0 W 'L Z m O C M 0 Z N r N lz W m f r a 0 J LL LL 0 W N N Z < L N 0 0 it Y, u, I r� Z o > W J 0 K < Z f m L Z 0 = 0 ] Z U 4 LL P 0 0 0 0 LL < Z I 0 K E m N O I 0 i 0 0 W N 0 W z_ J r 0 J I 0 rc LL W u Z r 0 0 r 0 J LL 0 W a iL 0 �0 z LL 0 u N J W L L LL 0 0 0 m Z 0 F L z a' W L 0 m L M 8 0 tr W L 0 u 9 m m W 0 2 F C W L u E W 3 ;a � J W J V Z 0 \ci 00 r < u J W ] L 0 0 W Z 0 a - Z 0 N Wp L Z Z J LL 0 ] W J r m r ] z J 0 N m 0 c! W 0 N o r o Z 0 0ej z PI 0LL C ION X 0 0 0 < % N 0 W u G \� < 0 O F j < 0 r1- 0 1 o ! rc W W F 0 W W 0 0 -I Z r r n O W 0 0 W ] ] W Ir m LL r o O 0 r < z jJ 0 JJ f 0 W < \ LL LL V W ] J j 0 I r O - N w Cl C7 w < < f' 0 W K N L L W < J m IL L m r 0 W C W < W W W L Z i z < D 0 Z 0 Z z< F r N O W L U WU z z OJ O O N i o 0 0 W N 0 W z_ J r 0 J I 0 rc LL W u Z r 0 0 r 0 J LL 0 W a iL 0 �0 z LL 0 u N J W L L LL 0 0 0 m Z 0 F L z a' W L 0 m L M 8 0 tr W L 0 u 9 m m W 0 2 F C W L u E W 3 ;a � J W J V Z 0 \ci 00 r < u J W ] L 0 0 W Z 0 a - Z 0 N Wp L Z Z J LL 0 ] W J r m r ] z J 0 N m 0 c! W 0 N o r o Z 0 0ej z PI 0LL C ION X 0 0 0 < % N 0 W u G \� < 0 O F j < 0 r1- 0 1 o ! rc W W F 0 W W 0 0 -I Z r r n O W 0 0 W ] ] W Ir m LL r o O 0 r < z jJ 0 JJ f 0 W < \ LL LL V W ] J j 0 I r O - N w Cl C7 w < < f' 0 W K N L L W < J m IL L �Ny DTOG1 N O�m O Ol O'°y0011 i11 0 Ap,mpy am m Dv;i� O 00 N� m 0 0 3 > = N z y N N T< Z S T ��a ~ z T (.1Z A p N n O r N N; S O Or) 3 0 D T T N N % N G1 D b 0 Jo y 2 N T ti H N Z 7C N y N p O m p m m m O D O D m y D n r m 2 D m m= O m Z 0 ; 0 0 D T mz N c Z O A~ W D O _�� OT OOZ=� •pCn;T tiA T O m N > m O A D Z T p ti 0 N x C 0 z< A n ~ m p ~ m �_ A c m z N X z Z p Z O O Zl0 my c c n f m v 0 n 0D m A r n � ti OONO N S O V v o �o 006 ycNO yo 0 Tz z fZ.)�� pox c 0 N MX-Nj N Z 0�0 ®no :2 m n n W p�OO p D; N Dclz .. (mj1 r fA x n n Zm MMO p yo mzz O y m ti pox c MX-Nj D n 0�0 mo* D mim N • mx 0 IN_n moo �Z_ mmi 3 vrAm C Dim mm0 msz r- c r T rr2O 11 for Z � 0 D*D �n Z_Z f1 y O 4 01 v =n ' z n 00 0 D3 � 0 0 c 0 m 2 OD ;u C TO D _T<aAz' ti Z y A << N N { Z � I Iti S >01 N (mj1 r fA Zm MMO yo mzz pox c MX-Nj D n 0�0 mo* mim • mx IN_n moo �Z_ mmi vrAm C Dim mm0 msz r- c r rr2O 11 for Z 0 D*D �n Z_Z f1 =o 4 01 v =n ' mm cn ,� 00 0 D3 � Suggested Affidavit for Home Improvement Contractor Permit Application For office use only NAME OF CITY/TOWN Permit No. Date AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c.142A requires that the "reconstruction, alteration, renovation repair, modernization, conversion, inprovement, removal, demolition. or construction of an addition to any pre-existing owner -occupied building containing at least one but not more than four dwelling units .... or to structures which are adjacent to such residence or building" be done by registered contractors, with certain exceptions, along with other requirements. Type of Work: 2 f�%}� Est. Cost 0Q Address of Work���t;� Y ®�%� Owner Name: Date of Permit Application: 10- 4-9Z' I hereby certify that: M Registration is not required for the following reason(s): _Work excluded by law _Job under 51,000 uilding not owner -occupied wner pulling own permit _Other (specify) Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. Signed under penalties of perjury: I hereby apply for a permit as the agent of the owner: o- 14 _ Z Ct J 82,)oto Date Contractor Name OR: Registration No. Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: to �t�- �2 -- Date Owner Name 61 7 a Ma ma n 3 c c A 3 Poo eD -v ut H OR z r m V) K 3 0 Z ca ca T m T (A m T m ?1 0 m 3 c c ? c c co rm w p', m 1p =rA ? A r T 7 r 7 cn Z C 0 > z 7C rX �J M v ti z O 00 CA Phone: 978-342-2660 JAMES A. TRUDEAU Adjustment Service Inc. P. O. Box 942 Fitchburg, MA 01420 claims(a,trudeauadi.coln Fax: 978-342-2699 Notice of Casualty Loss of Building Under Massachusetts General Laws, Chapter 139, Section 3B March 19, 2010 Building Inspector 120 Main Street North Andover, MA 01845 Board of Health 20 Main Street North Andover, MA 01845 Fire Department Dept. of Records 124 Main Street North Andover, MA 01845 Insured: Maryann F Ramsey Loss Location: 94 Saunders Street, North Andover, MA 01845 Insurance Company: Preferred Mutual Insurance Co. Policy No.: PHOO100525149 Date of Loss: March 14, 2010 File Number: 10-08542 Claim Number: 10004839 Type of Loss: Water Damage 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 writer and include a reference to the captioned insured, location, policy number, date of loss, and file or claim number. On this date, I cause copies of this notice to be sent to the person(s) named above at the address indicated by first class mail. Sincerely, Thomas Murphy Claims Adjuster Phone: 978-342-2660 JAMES A. TRUDEAU Adjustment Service Inc. P. O. Box 942 Fitchburg, MA 01420 claims(&,trudeauadi.com Fax: 978-342-2699 Notice of Casualty Loss of Building Under Massachusetts General Laws, Chapter 139, Section 3B March 19, 2010 Building Inspector 120 Main Street North Andover, MA 01845 Board of Health 120 Main Street North Andover, MA 01845 Fire Department Dept. of Records 124 Main Street North Andover, MA 01845 Insured: Maryann F Ramsey Loss Location: 94 Saunders Street, North Andover, MA 01845 Insurance Company: 'Preferred Mutual Insurance Co. Policy No.: PHOO100525149 Date of Loss: March 14, 2010 File Number: 10-08542 Claim Number: 10004839 Type of Loss: Water Damage MAR � 3 2010 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 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 313" is appropriate, please direct it to the writer and include a reference to the captioned insured, location, policy number, date of loss, and file or claim number. On this date, I cause copies of this notice to be sent to the person(s) named above at the address indicated by first class mail. Sincerely, Thomas Murphy Claims Adjuster