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FP6(rev.3f00) � r�. 'Q�J�, V�P ��tf1, ��� �'�/5
APPLICATION FOR PERMIT
City or Town :. ` - DIG SAFE NUMBER
_
C
Date
Start Date:
In accordance with the provisions of M.G.L. Chapter 148, as provided in Section 10A application is hereby made
by iZ'4-.� 'VV(S
(Full name ofperson,Firm or Corporation)
Address n {� T'�U' ( lh-� y Li coley ce (�'+
(Street or P.O.Box)(City or Town)
For permission to (state clearly purpose for which permit is requested) le � ff� �` /o- C'.r 2
Name of competent operator(If Applicable) !1 s yS 05y"x"C66/_S� Cert. No. f�
Date Issued.- Zj/2- ;/Y By 1 nw<) 19
(signature of Applicant)
Date of expiration � Tf Fee �y $ Paid Due
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FP6(rev.3100)
PERMIT
City or Town &cLt�pc '_V4 DIG SAFE NUMBER ,
Date L l I S_
Start Date:
Permit Number(if applicable)
In accordance with the provisions of M.G.L. Chapter 148, as provided in 10A this permit is granted
to
(Full name of perso ,Firm or Corporation)
for
Restrictions: Zv dt�7_ Yr csi✓Z
at
(Give location by street and no.,or describe in such manner as to provide adequate identification of location)
Fee Paid$ 5 �- This Permit will expire on
Signature of Official Granting Permit `� Title / 6LI'LZ__
This permit must be conspicuously posted upon the premises