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APPLICATION FOR PERMIT
IV . /,g ova =Date:
UMBER
City or Town ��e
Date 2- 1 �
In accordance with the provisions of M.G.L. Chapter 148, as provided in Section application is hereby made
by G
(Full name of Fe Firm or CorpoiatienJ
Address k
(Street orP.O.Box)(City or Town) /
For permission to (state clearly purpose for which p rmit is reques ' d) 6.)G �� �x `STY
Name.of competent operator (If Applicable) �Y421liz4
Date Issued-rejected 61� —/ By
( ign Lure o Ap !cant)
Date of expiration o " r�a �' Fee �� $ Paid Due
VJ.
3(rev.3/00) �X
PERMIT
City or Town .
D1G S=�UMBER ,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
to
(Full name of on,Firm or Corporation)
for o t
Restrictions:
(Give local' °.by street and no.,or describe in such anner as to provide adequate idenGlicalion of location) ,
=ee Paid $ This Permit will expire on
Signature of,Official Granting Permit Tille