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Date: �� APPLICATION iFO .PERM T
C. 82 S.40 M.G.L. START DATE'
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To: Head of Fire Department: r A.
City/Town
In accordant. with the provisions of Chapter 148, M.G.L. as provided in Section application is hereby made by:
Name: t--� .7 . .
- (Full name of person,fum or corporation)
Address: �a4tb—2 71 j-
(Street
(City/Town) (State) (Zip Code)
For Permission to:
State clearly the purpose for which the permit is requested:
location: r' '6
Name of competent operator if applicable: C ::� I
Date Issued Certificate of Competency#: `z`
{ } Date Rejected {
Date of Expiration: By:
Applicant Signature: i Fee Paid,( } Fee Due { } Amount:
Fire Department Number: .
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(I Applicable)
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Date: _ �7� Fi])h1�T1Tr11� DIG SAFE NUMBER
C.82 S.40 k-G.L. �i`��L�'li_Il .tt
START DATE:
In accordance with the provisions of Chapter 148,M.G.L.as provided in Section
this permit is granted to:
Name:
> ^•^ « I'(Fu(1 name of person,fumorcoporation)
For Permission to: to�b �
State clearly the purpose for which the permit is granted.
Restrictions:
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Location:
Fee Paid: is, rmi ill Expire
Signature and Title of Official Granting Permit: —