3 GABLES CIRCLE - CLAIM NOTICE C/
Butterwort & O'T€�o1e, Inc.
ADJUSTERS/APPRAISERS
FOR INSURANCE COMPANIES ONLY
P.O.BOX 8294
SALEM,MA 01971-8294
TEL. (978)741-5731
FAX (978)740-9109
claims. butterworthotoole.com
05/10/2021
FORM OF NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASS. GEN. LAWS, CH. 139, SEC.311
TO:
Building Inspector & Salem Fire Dept & Health Inspector
City Hall 48 Layfayette Street 120 Washington St 4th floor
Salem, MA 01970 Salem, MA 01970 Salem, MA 01970
RE: Insured: Joshua Devries
Address: 3 Gables Circle
Salem, MA 01970
Policy No.: 3228230
Loss of: 05/09/2021 Water/Back Up
File or Claim No.: 15-0393
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, Chanter 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
Adjuster
Member of
National Association of Independent Insurance Adjusters