AUG 2016 P&G Permits TG-160-349 MA4S ACH[US T S UNIFORM APPLICATION FOR A PERMW��PERFC+l �Y9��S PITT tltil� ��1�
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JOWTIE ADDRESS 46 OWNERS NAME
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TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL 0
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OWNER'S INSURANCE WAIVER:l am aware that ft licensee q n t have the kuurance covetage required by Chapter 142 0t to
Massachusetts General Lags„and that my signature on this permit application MMjW this requirement.
CHECK ONE t' NLY� OWNER, 0 AGENT
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