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CommittenteCognome e Nome/Stazione Appaltante ________________________________________________________________C.F. _____________________________________________________In<strong>di</strong>rizzo: Loc./Via ___________________________________________________________________ n. ___________Comune ____________________________________________________ Prov. __________ CAP ________________Recapiti del Committente: Tel. _________________________________e-mail pec:_____________________________________e-mail_____________________________________Direttore LavoriCognome e Nome ________________________________________________________________________________C.F. _____________________________________________________In<strong>di</strong>rizzo: Loc./Via ___________________________________________________________________ n. ___________Comune ____________________________________________________ Prov. __________ CAP ________________Recapiti del Direttore Lavori: Tel. _______________________________e-mail pec:_____________________________________e-mail_____________________________________Responsabile LavoriCognome e Nome ________________________________________________________________________________C.F. _____________________________________________________In<strong>di</strong>rizzo: Loc./Via ___________________________________________________________________ n. ___________Comune ____________________________________________________ Prov. __________ CAP ________________Recapiti del Direttore Lavori: Tel. _______________________________e-mail pec:_____________________________________e-mail_____________________________________Coor<strong>di</strong>natore per la SicurezzaCognome e Nome ________________________________________________________________________________C.F. _____________________________________________________In<strong>di</strong>rizzo: Loc./Via ___________________________________________________________________ n. ___________Comune ____________________________________________________ Prov. __________ CAP ________________Recapiti del Direttore Lavori: Tel. _______________________________e-mail pec:_____________________________________e-mail_____________________________________Data ________________________Firma________________________________<strong>Cassa</strong> <strong>E<strong>di</strong>le</strong> <strong>Terni</strong> – Zona Fiori 116/I, 05100 <strong>Terni</strong> (TR)fax 0744/443698 e‐mail sunico@cassae<strong>di</strong>leterni.it Pagina 3 <strong>di</strong> 10
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