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FP6 (rev.3/00) / 70��, �J C 1 U GOLlJ, 91 2D O'275
APPLICATION FOR PERMIT
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NUMBER
City or Town f V `
Date ! O_ ��-;`
in accordance with the provisions of M.G.L. Chapter 148, as provided in Section application is hereby made
by {��Cu� +
(Full name of person,-Firm or Corporation)
Address ��"'lam n��t✓ �f�vt y��r
(Street or P.O.Box)(City or Town)
For permission to (state clearly purpose for )which permit is requested)
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Name of competent operator(If Applicable) ~ Cert. No.
Date By
(Signature of Applicant)
Date of expiration!/�G4 �o�� Fee Z:2 Q $ Paid2 '—�.. Due
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6(rev.3/00)
PERMIT
City or Town ;V(2) or--4bu 2 ~ DIG SAFE=NNUMBER
Date
aStarte;
Permit Number (if applicable)
In accordance with the provisions of M.G.L. Chapter 148, as provided in this permit is granted
r� 1 (Full name of peerrson,F, or Corporation)
for �x i`d lj/z � � �7j7-C CSC-)
Restrictions: /�w`�ti� cT /7�n.At
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at
ive location by ofreet and no.,or describe'in such manner as to provide adequate identification of location) .
Fee Paid $ L—.)o This Permit will expire on
Signature of-Official Granting Rermit '' Title
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