196 JEFFERSON AVENUE - CLAIM NOTICE 266 AZ
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RECIPIENT OF ORIGINAL
SALEM CITY HALL LUIS PENA
93 WASHINGTON ST 196 JEFFERSON AVE
SALEM MA 019703527 SALEM MA 019702915
COPY OF ORIGINAL
August 11,2021
INSURED: LUIS PENA PHONE NUMBER: 877-447-9386
DATE OF LOSS: July 09,2021 FAX NUMBER: 877-292-9527
CLAIM NUMBER: 0635946684 PBW OFFICE HOURS:
PROPERTY ADDRESS: 196 JEFFERSON AVE, SALEM,MA
POLICY NO.: 004801475872
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 Selectmen
CITY/TOWN HALL: SALEM CITY HALL
ADDRESS: 93 WASHINGTON ST
CITY/TOWN/ZIP CODE: SALEM,MA 01970-3527
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,
Chanter 139,Section 3B is appropriate,please direct it to the attention of the undersigned and include a reference to the
captioned insured,location,policy number,date of loss and claim number.
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.
SIGNATURE AND DATE
Michael Muhammad
August 11,2021
Copy : SALEM CITY HALL
AUG 17 Am-01;u9
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PROP054
6000020210811TR008001662001001002323