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JOBS!TEJ DIDF.ESS L/,3 /�°111 . 'i /,,. , 1 OWNER'S NAME! 1 -I- L _ - i L i r l t
t,j; OWNER ADDRESS: t. - ' TEL: I `(/. j-s- �? V7✓c I FAX:1 -- _. I
•}' OCCUPANCY TYPE: COMMERCIAL �f i'aif?-�"' Q EDUCATIONAL U RESIDENTIAL�--
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CLE<=?�'r NEW:tif:0 RENOV:t?ION:t I RE ACEtfiEN T:LEI - PLANS SUSHI I tU: YES 0 NO;d
FIXI.I I PF=S ? F1.QQR— I ism: 1 1 -I 7 I j - _- 1 5 I 6 1 7 I B 0 1 10 I 11 1 12 I 13 1 4
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CC;.:i STOVE
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INSURANCE COVERAGE
1� a L abilfe insurance.i3 cy o:its st ts._ntla€squi aieltt._fii.Ch meals iialanniilr ct s of l<!iGL Ch.42 E i! 1'tio 0
I have currant-ii iC t"olt r ra s -� ?�-
II you have cliaciecLi;r_S..oiaase is i2~'ta the type.of cotlarans by checking the appropriate bon tiros!.
L(ABIUTkr INSU ANCI=Kis 1C'! il` OBER iYPT INDEMNITY U BOND 0 _ `.
OM'rruER'S L f-,ii'A1t CE iflJ-JVER:I am ateare that the lice-see doss no-.hays the insuiauce co'etaC�e required byChapte 42 of the - -
Mar.sachusct3 Gs:i&a!ate,and the?.my signature oT this pamile.appiicat,or w2 yes this requirement _
CHECK ONE ONLY: OWNER Lrf AGENT 0
aiGNA i URE OF OWNER OR AGENT --
hereby cersiy than-all of the delalls and information I have submitted(or entered)regarding this application are true and accurate is the best-dray
N1n,liadge end that all plumbing too;t and hisieliaiions pedvrnied under liia permit Issued for this application will be in c..n p}Ieno with all Pertinent
provision of die Miassacf+usab Slats Plumbing Coda and Cheater i42 of the General Lai=s. / .
PI,tJMBERiei.s i I 1 ll'',WADE; reg.-.�1ri_ t`;iV GF�'esnteiL.,7,L IC}D'1Se ii l 97,77 SIGi'I,=t t PEE
J ADDRESS: 7 _�y ip r ICOiri'lrY NAME3 �S fv �flt r(r ,i r �= ri -G J `�G C/1tr �✓
Cl {t : 2=--71_/lfI -r�s .f- !STATE i/i!-A ZIP:{ D?67 FAX: O-Y ""VS'�
TEL: `C�"-rla_=�g-VC I CELL:IS6IGjc 7o 91 EMAIL: l'�'-lei e �S'tJl-.f— Cam✓ 1,
MASTER[%JOUFti!Y!M N 11J LP INSTPILER E CORPORATION-I. I r1,�'y;' JP :t NERSHIP 0 ill !LW 0;,=1 .
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