HomeMy WebLinkAboutRadio Box installation permit - Permits - 15 CHARLES STREET 7/13/2012 (1>/e M 0,1 1 QleZ :�7 c/;a.WZ
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DIG SAFE NUMBER
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Date: — ,—i `) APPLICkTION FOR PERMIT START DA TE
C. 82 S.40 M.G.L.
To: Read of Department:
City /Town
Ln accordance with the provisions of Chapter 148, M.G.L. as provided in Section application is hereby made by.
Name: L , vv "'D/I/,)
(Full narfie'of person.firm or corporan
Address:
(Strcct or P o.Box) (City(-` (Zip Code)(C)
1 4 21*"For Permission to:
State clearly the purpose for which th e rrmi: I is requ ted,
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Location: de 7-5
Name of competent operator if applicable: ]Me dee- Certificate of Competency
Date Issued { } Date Rejected f I By:
Date of Expiration: Fee Paid Fee Due Amount:
Applicant Signaturt;-
Fire Department Number!
(If Applicable)
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Date: PERMIT DIG SAFE NUMBER
NUMBER
82 S.40 M.G.L. START DATE:
In accordance with the provisions ofChapter 148, M.G.L. as provided in Section this permit is granted to:
'Name: L- t W> >« eGOM-K—)�,,,C%Y
person,l or Corp�htio.
Fulj name 01 urn
For Permission to: (0 o
State clearly the purpose for which the p rant
sr to
_C
Restrictions:
Location: ly
Fee Paid: 's,C" 1, This Permit Will Expire Om
Signature and Title of^cial Ling Permit-
-->(THIS PERMIT MUST BE CONSPICUOUSLY POSTED UPON Tim PREmisEs.)