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APPLICATION FOR PERMIT
City or Town %� PIG-;,SAFE NUMBER
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in accordance with the provisions of M.G.L. Chapter 148,'as provided in Section application is hereby made
icy A� E
-(Full name or person,Firm or Corporaiion)
Address 1 c �T 'In
(Street or P.O.Box)(City or Town)
For permission to (state clearly purpose for which permit is requested) F f s'0 o'er
Name of competent operator(If Applacabte) Ohl r. y 1J5 /�/Lo�f ia/ ert. No. 1 3 2----
Date issued-rcptetf �.- By ✓ % �a,�
(Signatu o(appticano
Date of expiration�,�l�f��� ✓ Fee $ Paid Due
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FPS{rev.3100} ✓ l%, G �D�Jr, �aGu, �� 0-1275) ~
PE .R
City or Town DIG SAFE NUrJIEER
Date
Y . JPermit Number (if applicable) EStaurtDate:'
In accordance with the provisions of M.G.L. Chapter 148, as provided In this permit is.granted
(Full nama W person Firm of CwporaUon)
Restrictions,
(Qrva lo_-aZn byslree'and no.,ordascriba in such manger as to provida adopuala idanli6cailon of io:alion)
Fee Paid 1_5� ` _ -- . This Permit- 11-expire-on �/-i�,�✓�
Signature of C)HIcial Gra t(n Per
9 - Titles �----
This p rmlt fist si be conspicuoust posted upon the premi s ��`