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APPLICATION FOR PERNII1 r
,��?7 � /v�� =Date:
UMBER
City or Town �/YQ' /.T' A'
Date
In accordance with the provisions of M.G.L. Chapter 148, as provided in Section application is hereby made
by L. G✓ t3•�/S Go
(Full name at person,-Firm or.CCorporatien)
Address 7-7 Sf.
(Street or P.O.Box)(City or Town) /
For permission to (state clearly purpose for which permit is requested) i�S /l ���! 44-1�(
.��'l a f21�I!✓�2 .Z•,�- d�•( G�'�' Jam° /-� v Gt- /.?L/.
Nama of competent operator(If Applicable) Cert. No. A 3 S
Date Issued-rejected By
(Signature at Applicant)
Date of expiration Fee $ Paid Due
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PERMIT
City or Town � 'v �' DIG SAFE NUMBER
Date
Permit Number (if applicable) [Start Date:
In accordance with the provisions of M.G.L. Chapter 148, as provided in this permit is granted
to
// (Full name oiperson,Firm or corporation)
for L
Restrictions:
at �' /V �lldad A/ /' Js' C��v�'��c✓ �✓
(Give location by street and no.,or describe in such manner as to provide adequate identification allocation) .
Fee Paid $ !I This Permit will expire on
F
Signature of,Official Granting P � Title
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