HomeMy WebLinkAboutDumpster application and permit - Application - 6/6/2017 The Common eaQt�j of assac husa[j��(f`,s,
Department of Fare Serrv6ces
t ?T o ace Of the State Fire MarshaQ
��-- P.G.Box 1025 State Road,Stour,MA 01775
APPLICATION FOR PERIT
Date:
Permit No
(City or Town)
(1f Applicable} =Date
Safe
In accordance with the provisions of M.G.L, Chapter 10 as
provided in Section 527 C MR 34 ap 'cation is hereby made by � C( e:P—
(Full name ofperson,Firm or Corporation)
State clearly Address eio� !]�J �� 1� ^n
purpose for (Street orP_O.Bog City or Town) �I
which permit For ermissimto Locate dumpster for construction/renovation/demolition .�
is requested p of s t r u(f t u r e
Comments: dumpster must be 25 ' from structure or covered w en not in use
at H-t 'q I.;,,,_+A-c V%
(Give location by street and no,,or describe in such manner as to provied adequate identification o£location)
Name of competent operator ��-}t G� �v Cert.No.
(lf Applicable)
Date Issued--rejmteT el _ G - 13y
(Date of expiration Signature of Applicant)
3 / Fee$ `� Paid ✓� Due
----------------_ _ �_�—--'-------------- .cut-- -_ ._-.-_ �_---------- --- ----------.....
The Commonwealth of Massachusetts
Department of Fire Services
Office of the to ire Marshal
P.C.Box 1025 State Road,Stow,MA 01775 it
Permit No l
Date: �' s6
(City of Town) (1f Applicable) EDate
Number
In accordance vrith the provisions of M.G.L. Chapter 10as provided iu section 5 2 7 CM R 34
This Permit is granted to: Start
Full name ofperson,Firm or Corporation
Permission to locate dumpster for construction/renovation/demolition of structure
Comments: dumpster be 25 ' from structure or covered with tarp or plywood
Restrictions: a t end of workday
at t
Give location by street and no.,or describe ins ch manner as to provied adequate identification of location)
Fee Paid$ �'-z7
L
This Permit will expire /-I Z (Signature o o c grantmmit
g r , permit (Title)
TH1A PF=RMIT MI 1_Q`i' MR I°MVPP1r1 in1 IC1 V Pe)-QT9n 110f) .t TWP' PPPM1-QPQ