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APPLICATION FOR PERMIT
�. DIG SAFE NUMBER
City or Town '` `' )'
Date aStartate:
In accordance with the provisions of M.G.L. Chapter 148, as provided in Section application is hereby made
by // (Full nname of person,Firm or Corporation)
Address 6 7 C 2�,a v e--r S `C' 0 p'Z 1
(street or P.O.Box)(City or Town)
For permission to (state clearly purpose for which permit is requested) �2. l 4
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Name.of competent operator (If Applicable) - ,••, _�_ Ce". o. t", 2 1?—
Date Issued-rejected ?� i�/ � BY
( rgnatu f re of Applicant)
Date of expiration 010OA60 /0� 7� Fee � Pa d Due
Fev.3/00)
PERMIT
-ity or Town D1G SAFE NUMBER
gate
IStart :
ermit Number (if applicable)
i accotaance with tthe.provisions of M.G.L. Chapter 148, as provided in this permit is granted
(Full name of person,Firm or Corporation)
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estrictions: C'C'n2�ae isC' ram, ���� — A
(Give location by street and no.,of describe in such manner as to provide adequate identification of location) .
=e Paid $ - r This Permit will expire on
gnature of,Official Grantinc Permit Title
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