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APPLICATION FOR PERMIT
City or Town � a7
IG SAFE NUMBER
Date 7�� Start
In accordance
�with
htthe provisions of M.G.L. Chapter 148,as provided in Section application is hereby made
by
(VFW/name of pe rm or Corporation)
Address
C� o�s��✓
(street or P.O.Box)(City or Town)
For permission to (state clearly purpose for which permit is requested)
Name.of competent operator(If Applicable) C4rt.
Date Issued-rejected I J-J - 2 By
(Signature of Applicant)
Date of expiration �)(O(>n ® < Fee $ Paid Due
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PERMIT
City or Town DI=�NUMBEIRI
Date
Start Date:
Permit Number (if applicable)
n accordance with the provisions of M.G.L. Chapter 148, as provided in this permit is granted
Q' 74_1_2
ull name of person,Firm orCofp�Venj
or 1>/T D4//
'iestrictions:
it
—�— (Give toca lion by street and no.,or describe in such manner as to provide adequate identification of location) .
=ee Paid $ This Permit will expire on Ae5;?����o�
r
)ignature of-Offici7Grantinermi Title.. .-- 7—x_t —— - —— .,. .. . . —f^r4 aIr,nri + In r-%rnmicoc