HomeMy WebLinkAboutMiscellaneous - 26 MorningsideSafety Insurance
Wo
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner or Board of Health or
Inspector of Buildings Board of Selectman
City Hall City Hall
NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845
RE: Insured:
Property Address:
Policy Number:
Claim Number:
Date of Loss:
Company:
DAVID EVANGELISTA and ALISSA EVANVELISTA
28 MORNINGSIDE LANE, NORTH ANDOVER, MA
HMA 0340400
BOS00042258
1/21/2014
Safety Indemnity Insurance Company
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 attention of the writer and include a reference to the captioned insured, location,
policy number, date of loss and claim number.
Daniel Olsen Claim Examiner
Safety Insurance Company
Homeowners Claims Unit
P. O. Box 55098
Boston, MA 02205-5098
Phone: (617) 951-0600 EXT 3323
Fax: (617) 531-2762
Email: Danie101sen@Safetylnsurance.com
3/24/2014
SEPTIC SYSTEM INSPECTION FORM
ADDRESS 2 rA ►'✓1 efri� mss+
DATE INSPECTEDc-
PROPERLY FUNCTIONING? (1) N
WEATHER CONDITIONS
COMMENTS:
ISA i E.!: aVALI T Y TES d &-
�--) 2 ?ES0� i S?
DYE TEST PERFORMED? Y N
DATE?
SKETCH:
C
1. h aniL,
2. Street Address .2tf %nom U 'tyt to
3. 1-i€ iv many members are in your household?
4. What type of sewage disposal system do you have?
r ! cesspool
r septic tank and leaching area
connection to municipal sewer
J other (describe)
❑ do not know
5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health?
❑ yes ❑ no �;Xdo not know
6. How: -old. is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years ❑ 11-20 years
over 20 years ❑ do not know
'. 1 -las your sewage disposalsy m been rebuilt or repaired?
D_ yes Elno PT do not know
If yes, approximately how long ago?
years. What was done?
6. ;-low frequently is your sewne disposal system pumped out? ❑ annually
D every 2-4 years LJ every 5-10 years ❑ over 10 years ❑ never
9. Have you had any problems with your sewage disposal system? ❑ yes �o
if yes, what problems?
❑ repeated pump -outs needed
❑ system clogs, backs up, or drains slowly
❑ odors
❑ sewage surfaces through ground
10. .-low many of each appliance are connected to your sewage disposal system? %
washing machine dishwasher garbage disposal
dehumidifier drain sump pump toilet {—
ra_�f/pavement drains shower/bathtub
11. "lease state the brand and type (liquid or powder) of detergent you use for:
dishwasher -
clo4heswasher /11
12. Does yo. , property have a lawn? Qy—es ❑ no
If I -es, a; +roximately what size?
❑ less'. an 1/4 acreacre ❑ 1/2 acre ' El3/4 acre EJ1 acre
❑ mor( ; lan 1 acre (Specify) acres
13. How oft. do you fertilize your lawn?
144. of a-. iications per year
`season(� ," the year
14. Please st .he brand and type (liquid or granular) of lawn fertilizer you use:
a�-V5 a�4�LSt C, 2
❑ C _ck here if your lawn is maintained by a professional landscape contractor.