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' ' DIG SAFE NUMBil ,
Date: APPLICATION FOR,FE MHT START DATE; Y
C.82 S.40 M.C.L. .
To: Head of Fire Department: �� G�`�-� A iN d Q o o� MA
City/Town
In accordance with the provisions of Chapter 148,M.G.L. as provided in Section� application is hereby made by:
.,Name: ,r S
(Full name ofperson,firm or corporation)
Address: 4 ��a r!n,'�L� 4 ( ���p ��r �; nC
(Street or P.O.Box) [ (Citf/Town) (State) (Zip Code)
For Permission to: ` "11 P r-
State clearly the purpose for which the permit is re uested:
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location: 0gate St
Name of competent operator if applicable:) d ` Certificate of Competency#: / Q^ :)t�
Date Issued{ } Date Rejected { }: By:
Date of Expiration: Fee Paid { } Fee Due { } Amount:
ApplicantSignaitxre: __�� , ��.,,�,� A,;,; 'Fire Department Number:
(If Applicable)
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Date: �/� " 5 FE.]I.41V'1i�1l Dfc 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: A , C, cAJ /4- U/dam j
Full name of erson,rum or corporation)
For Permission to: !.y 5 k l/ �' i 0� r ei/ l "Z �i� tse��o c� G C S' "o ��.`� -f %/7
State clearly the purpose for which the pe `" is granted:
Restrictions'
Locaiion: LJC�I�-
Fee Paid: , is P = ill Expire O
Signature and Title of Official Granting Permit: