416 Lafayette Street - NOTICE OF CASUALTY LOSS TO BUILDING 96�
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Butterworth & 0"I"oole, Inc,
ADJUSTERS/APPRAISERS
FOR INSURANCE COMPANIES ONLY
P.O.BOX 8294
SALEM,MA 01971-8294
TEL. (978)741-5731
FAX (978)740-9109
claim sna s@butterworthotoole.com
10/27/2021
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 Lafayette Street 120 Washington Street 4th
floor
Salem, MA 01970 Salem, MA 01970 Salem, MA 01970
RE: Insured: Fabio Bardini
Address: 416 Lafayette Street
Salem, MA 01970
Policy No.: 2193825
Loss of: 10/27/2021 Wind
File or Claim No.: 15-0906
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 ra 1 1
OCT 288 PH"
OCT
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Member of
National Association of Independent Insurance Adjusters