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Date: j_ '_� 5 APPLICATION FOR.PJS:d1L�l.LV1 HT START DATE: Y
C.82 S.40 M.G.L.
To: Head of)Fire Department: �� D fl clmk-Q,r yyL A
City/Town
In accordance with the provisions of Chapter 148,M.G.L. as provided in Section application is hereby made by:
Name:
y (Full name of person,—firm or corporation)
Address: I'n ti^fl ►�/Yt�4. /� Ll�-_0._eo C•e_ Yyk/3, of �-Ll
(Street or P.O.Box) — +r (City/Town) (State) (Zip Code)
For Permission to: s c , ,� C ;��,( { 6- , —( ,
State clearly the purpose for which the permit is zeq ested:
•Location:
Name of competent operator if applicable; s y ors Certific to of Competency#: 0 —,
Date Issued { } Date Rejected { }: By:
Date of Expiration: Fee Paid { } Fee Due { } Amount:
Applicant Signature: Fire Department Number: .
(If Applicable)
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PERMIT
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Date: _ ( ''/S JL �[�j RJ.V 111' Dic SAFE NUMBER
C.82 S.40 M.G.L. START DATE:
in accordance with the provisions of Chapter 148,M.G.L.as provided in Section this permit is granted to:
ame: w y/
'( ull,name of persor4 firm or corporation)
For Permission to: �S��/ /L� c r�U c>✓I ��r�t c/ �sC'' l�.s. _l
State clearly the purpose for which the permit is grante :—
Restrictions:
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Location: 3 / / 7 G
Fee Paid: 1_5� — This Permit Will Expire On:
Signature and Title of Official Granting Permit: