HomeMy WebLinkAboutRadio box installation permit - Permits - 4/26/2016 The Commonwealth of Massachusetts
= Department of Fire Services
Office of the State Fire Marshal
P.0.Box 1025 State Road,Stow,MA 01775
APPLICATION FOR PERMIT
Date:
L2 A k Permit No
(City or Town) (If Applicable) Dig Safe Number
In accordance with the provisions of M.G.L. Chapter as
provided in Section application is hereby made Start Date
by
(Full name of person,Firm or Corporation)
State clearly Address Cam✓ G1 /L-J-
purpose for (Street or P.O.Box City or Town)
which permit For permission to C� t ��4 �dr lc�,.z %� lOr-,c e ; �r- �c� r c�c• S _
is requested
q �.�1 .fit', 2 Cf y y 'V. Y"t> C r a /c)
Comments:
at
(Give location by street and no.,or describe in such manner as to provied adequate identification of location)
Name of competent operator 712.v" �14 1�lC q rr- �I u Cert.No. 'Z I Z Z 'i j7
(If Applicable)
Date Issued-rejected By
(Signature of Applicant)
Date of expiration Fee S Paid Due
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The Commonwealth ®f MsssaChusetts
Department of Fire Services
Office of the State Fire Marshal
P.0.Box 1025 State Road,Stow,MA 01775
Lu ��'�"�`�0 ,` Permit No PERMIT Date: ,
(City of Town) (If Applicable) Dig Safe Number
In accordance with the provisions of M.G.L. Chapter as provided in section
' / / Start Date
This Permit is granted to: �,�. �L.f, �,,�
Full name of person,Firm or Corporation p
Permission to /�.S�.�� r�.��,.Z ���"7a-17i �d- �c-� aL
Comments:
Restrictions:
at _ Jol U
(Give location by street and no.,or describe in such manner as to provied adequate identification of location)
Fee Paid$ JV r /
This Permit will expire (Nb p- (Signa is r ig perms, ting pernut 'l Title)
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