HomeMy WebLinkAboutFire Dept Permit - Permits - 1/27/2012 FP6(rev.3/00) V. �Ox % ��7, U C CJ �OLI�� �0-f/275
APPLICATION FOR PERMIT
=Date:
UMBER
City or Town ° ���'� '�-''�'"`
DateStart
In accordance with the projy ssions of M.G.L. Chapter 148, as provided in Section application is hereby made
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by
(Fult name of person, um Or Corporation)
Address
J (Street or F.O.Box)(City or Town) l
For permission to (state clearly purpose for which permit is requested)
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Name.of competent operator (If Applicable) eC cry -U 2 C( 12 Cert. No. (?
Date Issued-re}eated /,7- By
(Signature of Applicant)
Date of expiration Un 6n ��rr°LE ®� Fee S--y $ Paid v°--- Due
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16(rev.3/00)
PERMIT
City or Town .�/� �/���/� DIG SAFE NUMBER
Date
Start Date:
Permit Number (if applicable)
In accordance with the provisions of M.G.L. Chapter 148, as provided in this permit is granted
i (Full name of person,Firm or Corporation)
for df- ter. r-
Restrictions:
at
(Give location by street and no.,or describe in such m eras to provide adequate identification allocation) .
Fee Paid $ ,S� ,This Permit will expire on l2w1-1
Signature of'Official Grantin Perm' Title
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