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Town Of North Andover, Massachusetts Form No. 1
BOARD OF HEALTH
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° APPLICATION FOR SITE TESTIN TION
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Applicant
NAME ADD S TELEPHONE
Site Location
Engineer
NAME ADDRESS TELEPHONE
Test/Inspection Date and Time
CHAIRMAN,BOARD OF HEALTH
Fee Test N o.
S o. D.W.C. No. C.C. Date Plbg. Permit No.
Town of North Andover, Massachusetts Form No. 1
NORTH BOARD OF HEALTH
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APPLICATION FOR SITE TESTING/INSPECTION
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Applicant
NAME ADDRESS TELEPHONE
Site Location - 4�
Engineer
NAME ADDRESS TELEPHONE
Test/Inspection Date and Time
CHAIRMAN,BOARD OF HEALTH
Fee Test No.
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
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PATRICK J. DONOVAN ASSOCIATES, INC. m
Claims and Loss Adjustments
P.O.BOX 110
WAKEFIELD,MA 01880
Tel. (781)245-5540 -FAX(781)245-7016
February 13, 2003
Building Commissioner
City or Town Hall
North Andover, MA 01845
Insured : Edward A & Sandra C O'Toole
Property Address : 40 North Cross Street, North Andover
Insurer : Vesta/Shelby Insurance Company
Policy Number : HM71408
Type of Loss : Water Damage
Date of Loss : 02/08/03
Our File # : WAP34468
Claim has been made involving loss, damage or destruction of the above-captioned
property, which may either exceed $1,000 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 attention of the writer and include a reference to
the captioned Insured, location, policy number, date of loss and file number.
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.
Vern Laws, Adjuster
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Insurance Adjustment Service, Inc.
936 Roosevelt Trail Unit 5
Windham, Maine 04062
207-892-0522
Fax 207-892-0526
UNDER MASSACHUSETTS GENERAL LAWS CHAPTER 139 SECTION 313
Date: April 20, 2011
TO: Board of Health/Building Inspector
RE: Insured: Edward OToole
Property Address: 40 North Cross Rd.
North Andover,MA
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Date of Loss: 2/15/2011
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Policy Number:
Type of Loss:
File or Claim Number: 71989
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 1.43, 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,
Matt Martin
Adjuster
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