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APPLICATION FOR PERMIT
City or Town cm rIA-N c =Date:
UMBER
Date 11 _ 1 — 1 J
In accordance with the provisions of M.G.L. Chapter 148, as provided in Section application is hereby made
by
(Full name o/person,Frtn or Corporation
Addressr.Ptl--v '
(Street or P.O.Box)(City or Town)
For permission to (state clearly purpose for which permit is requested) I 6
Name.of competent operator(If Applicable) --)c� Cert. No.
Date Issued-rejected f'/—��%� By
(Signature of Applicant)
Date of expiration 1/P0n r10,-'!Gc--) Fee _ ,-Cr� $ Paid Due
---
P012
_ 1ira�C�ri��e
)s(rev.3/00)
PERMIT
T'
City or Town DIG SAFE NUMBER
Date
CStartDate:
Permit Number (if applicable)
In accordance with the provisions of M.G.L. Chapter 148, as provided in this permit is granted
to -.rr;l� � '
l (Futi name of person,Firm or Corporation)
for
Restrictions:
at (Give location by street and no.,or describe'in such manner as to provide adequatteldentilication of location)
Fee Paid $
- _ -- Thi r it w�ex on Rio�� �os�Lr�,Cs/•� �z-,
Signature of'Official Granting Per
- Title
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