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Address 23 Title of File
Pa9e of
Date f=ile Open:
Date file closed:
C►oc Docuiment/Action Title Date of Refer to other aurpose of I�ocumecnt Act
action Document/ docunvent/ / ion and notes
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Board of Appeals — Board of Health = Planning Board _ Conservaflon Comm' " _
rssion Building Department
t
I
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
TOs Building Commissioner or Board of Health or
Inspector of Buildings Board of Selectmen
Town of N. Andover ) ( Town of N. Andover !
) (
N. Andover., MA 01845 ) addresses ( N. Andover, MA 01845
)
REs Insureds Michael & Diane Sullivan !
Property address- 223 Chestnut Street
N. Andover, MA 01845
Policy No. HP 1016117
Loss of October 16, 19 91
File or Claim No. WAP 13630(water)
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, CH. 139, SEC. 311
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.
Adjuster
Titles
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.
PATRICK J. DONOVAN ASSOCIATES, INC.
P. 0. BOX 110 11/15/91
WAKEFIELD, MA 01880
Sign ure d d to