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APPLICAMON FOR PERN/11T DIC SAFE N�JNSER,
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C. 82 S,40
To: Elead of Fire Department: _N0,14
City /Town
In accordance with the provisions of Chapter 148, M,C]G.L. as provided in Section application is hereby made! by
Name: lam. at name of(JU" z
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For Permission to: ff
State clear the,purpose for AtlVch 6he perrqat is requested 4
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Location: C547C 00d "fo
Name of competent operator if a licable: hetlWL-4 Koedef Certificate of Competency 4:
Date Issued ( ( Date Rejected By:
Date of Expiration: Fee Paid Fee Due Amount:
Applicant Signature- Fire Dep a=eiit Nurnber
(If Applicable)
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PERNUT Dir,SAFE NUMBER
Date:
C.82 S.40 M. START DATE:
In accordance with the provisions of Chapter 148, M.G.L. as provided in Section this permit is granted to-.
Name: Z— romp"
(.Full nuM ofpers"fum or. ormo
For Permission to: /OaS77(12-
State clearly theUTPOSe for W�ichj)e permit is granted-
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Restrictions:
Location: S7S 9 > ----------------
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Fee Paid:
Signature and Title of Official Granting Permit:
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