12 Forrester Street 10-30-17 claim RECEIVED LaMarche Associates
5 North
FEB 2 7 2018 Chelmsfo doMA 01824
806-349-1525
CITY OF SALEM Fax: 978-256-8590
BOARD OF HEALTH
February 22, 2018
Building Commissioner/Inspector of Buildings
Salem, MA 01970-4002
Board of Health/Board of Selectmen
Salem, MA 01970-4002
NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASS A 'HUSETTS GENERAL LAWS CHAPTER 139 SECTION 3B
captioned
000.00 or cause Massachusetts General Laws
Claim has been made involving loss, damage or destruction of the property
below, which may either exceed $12 notice under Massachusetts General Laws
Cha ter 143 Section 6 to be applicable. If any
ro riate, please direct it to the atte umber,
date the of loss,er and
cause
Cha ter 139 Section 36 Is appropriate,
insured, location, policy number,
include a reference to the cap
of loss and LA file number.
Insured: Edward & Ann Czarnecki
Loss Location: 12 Forrester Street
Salem, MA 01970 4002
policy Number: HO17040727
Date of Loss: 10/30/2017
Cause of Loss: Wind
LA File Number: MA-2-34334
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.
Kevin Gabbett
Adjuster
1MarcM1e A4o PB9s 1 Inc
1 SOO-349-1525