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UNWHEATER
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Mwmt rbi bInSUranm policy 1 l substantialOWWWt
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If YOU - M M: I XM please1 ✓. I: the type of coverage 1 checking
appropriate 11 below.
POLICYLIABILITY INSURANCE
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OWNER'Sft
that Ihe Ikeraw
Il1.r no haveto Insurance MI
vamp re"ked by Chapter 142 of the
Mmackisefts General Laws, and that my 1- 11 this Mud applicationL.Mr 1. LI
uivemot
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY.OWNER ■ AGENT ■
h'mby cerfifji dW d of the detak and int mmdm I haw submitted (or entered) repdkthis appkadm am true and accurate to the best of my
Knowledge and �tb work and Instailedons performed under the Permit Issued for this a0katlort will be In =V with all Perdnent
Plumbing Cads and Chapter 142 of the General Laws,
PLUMBER/GASFITTER NAME. �+ LICENSE #® SIGNATURE
COMPANY NAME ADDRESS:
CITY: -1 STATE i DP O FAX
TEL CELL: i L: /�
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MASTER ❑ JOURNLP INSTALLER ❑ coRPORATION 0 #(=PARTNERSHIP p #LLC 0 #