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APPLICATION FOR PERMIT
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City or Town AJ`3D0VPrL DIG SAFE NUMBER
Date (�j — 2-0 1 1
Start Date:
In accordance with the provisions of M.G.L. Chapter 148, as provided in Section application is hereby made
by �C ��d:�rQ t — EA )N C
(Full name of person,Finn or CorpoAra�tion)
Address
(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)
Date Issued-r et-ed. % AT By
(Signature of Applicant)
Date of expiration U0olZ1146�� <r Fee _ $ Paid Due
Qom . - .� � (9016 94&21�
'6(rev.3/00)
PERMIT
City or Town / V ��OI�C�l_ DIG SAFE=NNUMBER .
Date 4- ^ 3 r 2-0
:St:artDate:
Permit Number (if applicable)
In accordance with the provisions of M.G.L. Chapter 148, as provided in this permit is granted
l (Full name of person,Firm or Co oration)
for
Restrictions:
/ [ q
at �J/ �( U(/L- - SIL- V�7 2—
(Give location by street and no.,or describe in such manner as to provide adequate identification of location) .
Fee Paid $ S� This Permit will expire on 6Z6D�
c _
Signature of Official Granting Permit Title / '
�..,s�.