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DIo SAFE NUMBER.
Date: 1)--D IS APPLICATION FOR.P ERMHT
START DATE'
C.82 S.40 M.G.L.
To: Dread of Fire Department: /Q Q n Y)J„n t L��"
City/Town
In accordance with the provisions of Chapter 148,M.G.L.as provided in Section application is hereby made by:
ti ame:
' (Full name ofperson firm or corporation)
Address: a 1'� �Y�i 1 sJ 4� e-<`� 4 y' ��c C �C 1 -,f of
(Street or P.O.Box) (Cityfrown) (State) (Zip Code)
For Permission to: 0 �,n S 4`/- c /lJ7> e f cx ���r 7��G,-�,�, L,P61--
State clearly the purpose for which the permit is requ sted:`1_1 y
Location:
Name of competent operator if applicable:` ��i,� �r o -
.i� r�,�-�^�;;��_c,. � Certificate of Competency#:
Date Issued { } Date Rejected { }: By:
Date of Expiration: 4 Fee Paid { } Fee Due { } Amount:
Applicant Signature: Fire Department Number: .
(If Applicable)
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Date: t�_1 PERMIT DIG 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:
Name: ': "14r� ' o
(Full narrf6ofperson,firm or eolporattgq)
For Permission to: �I a 'T ;I�S� /r)T3 6 0 ca' � c � n< (� (-—
State clearly the purpose for which the permit is g ante :
17
Restrictions:
Location: ;' ✓► y "�
Fee Paid: This Permit Will Expire On:
Signature and Title of Official Granting Permit:
Sitewalk Checklist for Sketch
Sketch Checklist: o Tank to House o Leech Bed
o All Windows that apply o Second Stage Regulator o Driveway
o All Doors that apply to Windows o Temporary Tank Location
o All Sources of Ignition o Second Stage Regulator o Only 1 temporary tank
o Second Stage Regulator to Doors needed/allowed
o All Measurements o Second Stage Regulator o 2 temporary tanks
o Tank to Windows to Sources of Ignition needed
o Tank to Doors o Second Stage Regulator
o Tank to all Property Lines to Tank(including
o Tank to Sources of temporary tanks where
Ignition applicable)
Comm nts (notes from technic1 to office):
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Office Notes/Correspondence(customers/technicians/other customers):
itewalk Drawing:
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