4 Vista Avenue 12-18-20 claim RECEIVED
MAR 0 2 2021
CITY OF SALEM
BOARD OF HEALTH
Butterworth & O'TooCe, Inc.
ADJUSTERSIAPPR4ISERS
FOR INSURANCE COMPANIES ONLY
P.O.BOX 8294
SALEM,MA 01971-8294
TEL. (978)741-5731
FAX(978)740-9109
claimsruibutterworthotoole.com
03/02/2021
FORM OF NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASS.GEN.LAWS,CH. 139,SEC.3B
TO:
Building Inspector & Salem Fire Department & Health Inspector
City Hall 48 Layfayette Street 120 Washington Street 4th
floor
Salem,MA 01970 Salem,MA 01970 Salem,MA 01970
RE:Insured: Erci Andrade
Address: 4 Vista Avenue
Salem, MA 01970
Policy No.:
Loss o£ 12/18/2020 Water/Burst Pine
File or Claim No.: 15-0168
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.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.
If no reply is received from your office within ten days,we will assume you have no liens of any type against this
property and we will recommend to the insuring company that this claim is paid.
John Foley
Adjuster
Member of
National Association of Independent Insurance Adjusters