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APPLICATION FOR PERMIT
/ =Date:
UMBER
City or TownC
Date
In accordance with the provisions of M.G.L. Chapter 148, as provided in Section application is hereby made
by C �"1 -' RC/A'1, t NI LE l
( ull name of person,Fi or corpordtienJ
Address P c (,1 3 IA S3
(Street or P.O.Box)(6ity or Town)
For permission to (state clearly purpose for which permit is requested) I2t f UY.A 1 L L X l 1 1 K :7,P 1,14L ,z:'PZ
Name.of competent operator(If Applicable) jksc N I h I E, Cert. No. 09 9 cl S
Date Issued-r-e}eeted /� - By
( ignature of Applicant)
Date of expiration C✓1°� ✓ Fee �`��' $ Paid - Due
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PERMIT
IGSAFE NUMBER
City or Town 9� `.�����'''�- D_ '
Date_—�- Z
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 lj A
(Full name of person,Firm or Corporation)
for (?IfLo AT ('x/S7,K)61 PtZ ��rlc�c2
Restrictions:
(Give toc�by street and no.,or describe in such manner as to provide adequate identification of location)
Fee Paid $ This Permit will expire on
p _
Title
Signature of,Official Granting Per
o✓ ' ��
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