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Date: APPLICCATIGN FOL`..PE MHT
START DATE:
C.82 S.40 M.G.L. 1'
To- Head of lFire Department. 1�L) odou- 'rna—
City/Town
In accordance with the provisions of Chapter 148,M.G.L. as provided in Section application is hereby made by:
Name: ��� `r r���
��"" (Full name of person,firm or corporation) '
Address: 'sllrtrr7et�(C�t.� �/ -� CC,L11-4nc
(Street o��r,P.O.Box) (Cityfrown) (State) (Zip Code)
For Permission to: v 15 7`4/� �`` f�1//Un e; �tx t"T �c� C, P C-
State clearly the purpose for which the permit is requested:
location: -2 4z L
Name of competent operator if applicable: n, ,; ne , s` Certificate of Competency#:
Date Issued { } Date Rejected { }: By:
Date of Expiration: Fee Paid ee Due { } Amount:
Applicant Signature: Fire Department Number: .
(If Applicable)
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Date: J 1 :PERMIT DIG SAFE NUMBER
C.082 S 40M.G.L. START DATE:
In accordance with the provisions of Chapter 148,M.G.L. as provided in Section this permit is granted to:
Warne: J44Af-rqr!� L�hfi' �'T /Uy1 � "U'�- �Ei�vNY�1L l�L1 '� �d. V�
'(Full name of erson,£urn or corporation)
For.Permission to: l!l�O C �-1161" 1 1,2 cs c. G
State clearly the purpose for which the permi--t is granted:
Restrictions: /�
Location: 3 P
Fee Paid: 3'his ill Expire
Signature and Title o Official Granting Permit:
(THIS PERMIT MUST BE CONSPICUC)TI.CT.V Pne•rvT TT-, T
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)
Comments (notes from technician to office):
Office Notes/Correspondence(customers/technicians/other customers):
Sitewatk Drawing:
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DIG SAFE NUMBED•
Date: Al'PLIC jIGI iE1MIT START DATE: Y
C.82 S.40 M.G.L. �.
To: Head of Fire Department: 0 e0i d6 -u`' p1y
City i Town
In accordance with the provisions of Chapter 148,M.G.L.as provided in Section application is hereby.made by:
Name: 44
, ^^ (Full
AAname ofperson,fumorcorporation)
Address: X/i1er' twc,( `e,01-en( 7t'1s ,,) Z/
(Street or P.o.Box) t (City/Town) (State) (Zip Code)
For Permission to: j "-� t/ �`` 0-0 C-c cln t��" i c�v�e� �j d .� _
State clearly the purpose for which the permit is requested:
.Location:
Name of competent operator if applicable; rtificate o Competency#:
Date Issued { } Date Rejected { }: By:
Date of Expiration: Fee Paid ee Due { } Amount:
Applicant Signature: ,; cs,�� ve Fire Department Number:
(if Applicable)
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, D �" ]PE DIG SAFE NUMBER
Date IT
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: t�t%r"� 2 Znler -)CJ-i 0,14 1 "u^-�7 C/-r�'.��-r'%�t,� l�''I �' �i d �"✓/
'Vull name of erson,fum or corporation)
For Permission to: 1161 ► 9 !,2 c c,--o r-L, ew l C 06- 5'1 d rep,-) 4,
State clearly the purpose for which the permit is granted:
Restrictions:
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Location: %'' I—e h �/� _ .
Fee Paid: This Permit Will Expire On: ''—^
Signature and Title of Official Granting Permit: /' .00
(THIS PERMIT MUST RF.6-()N.cvrr-rtnr rcrD YT_-__
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 I 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)
Comments(notes from technician to office): n /
f!-e .0 /- /d lG cr. ;
16ca �, ' ��� 9 30 7
Office Notes/Correspondence(customers/technicians/other customers):
Sitewalk Drawing:
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