0132 DERBY ST - BPA-05-603 ROOFING JACKET fL�f18�Mtl6Y�E fNA94ND APPROVED 8Y THE
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CITY OF SALEM
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Is Properly Loaded In
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Permit to:
BUILDING PERMIT APPLICATION POR:
(Circle whichever apply) (Roof,)Aeroof, Install Siding, Construct Deck. Sh , Pool,
�pair/Replace, Other
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSM
TO THE INSPECTOR OF BUILDINGS: '•
The undersigned hereby applies for a permit to build accortLig,to the Wowing
spectfiations:
Ownmes Name �G Q
Address & Phone
Architect's Name
Address & Phone ( 1
Mechanics Name 1211FI✓ v
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Address & Phone YOC
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SNOM UNDER THE PENALTY,
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:
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fI,t1IS,M16i�E f �Mfli ApPROVEO BY THE
A &P4W=PRIOR TEA P.BAWT AEWG GRANTED
• CITY OF SALEM
No.
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BWLDING PERMIT APPLICATION FOR:
PannR t0:
(Curia ttAtiWtWW a") IrWa Siding, COrtatruot DOCK Shad. Pool.
. Oltwr:
PLEASE PILL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS IN PROCESSWG
TO THE INSPECTOR OF BWLDING&
Tlw taftdaraiprwd haraby aPPin br a pem* to build according to ttw tolbwing
Omuta Name
Addraaa a Phono /�L /�//�� r � 7d) 729 " YET
Arr hitW& Nme
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Addrm a Phone YO-C' tSsc-A, sk Sk-)",o 17-1)
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SIGNED oNDER f THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
S A lfml)c
l
IiML PER =TOL
Na �=
APPLICATION FOR
PE TO
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LOCATION
pERLgT GRANTED
20 o�
OR OF ILDINGS
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Samuel F. McCormack Co., Inc.
Insurance Adjusters and Appraisers
Samuel F.McCormack Co.,Inc.
AUJUSIERS AND APPRAISERS
April 29, 2019
Salem City Hall
Building Inspector
93 Washington Street
Salem. MA 01970
RE ASSURED: Derby Bentley Condominium Trust c/o Roger Falcon
LOSS LOCATION: 132 Derby St- Unit 5 Bldg 1, Salem, MA 01970
POLICY NO: BP11017076
TYPE OF LOSS: Water
DATE OF LOSS: 04/28/2019
OUR FILE NO: 19-01379
To Whom It May Concern:
Claim has been made involving loss, damage or destruction of the above-captioned property, which
may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 to
be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is
appropriate, please direct it to the attention of this writer and include a reference to the above-
captioned insured, location, policy number, date of loss and claim or file number.
Thank you for your anticipated cooperation.
Very truly yours,
Edward Bennett
Adjuster
eb@mccormackadjuster.com
cc: Board of Health
42 Holbrook Avenue,Braintree,MA 02184 1-800-972-5399(781)843-1222 Fax(781)849-8191
125 Waterhouse Road,Bourne,MA 02532(508)403-2600 Fax(508)403-2602
www.mccormackadjuster.com