LP Tank Install `N
TitV of #slew, Assasr4uat is Fee Due$10.00
c Ck.# 14 Cash
FIRE DEPARTMENT • FIRE PREVENTION BUREAU
48 Lafayette Street Rec'd by:
Salem, Massachusetts 01970
/ � S
To: HEAD OF FIRE DEPARTMENT (Date)
Application is hereby made in accordance with the provisions of Chapter 148, Mass. General Laws; and 527CMR6.00 made under
authority thereof, by the undersigned,for permit to install Liquified Petroleum Gas storage tank or tanks,for the person or persons
and at the loc ioq� ed herein:
'
lJ/�Gi'ic? /�ii'i�'
Name of Owner,,/ J C Address: 2 "vPwe1'e/_V1 ey-h--
Number of Tanks: Capacity of Each Tank: IG� �/aril Total St ge: w
Company 7�in r'I.rhG��T/S Address:/3i L PAO/J Installer:
ritten igna ur
Issued by: Inspector NP. LaPointe Date: Feb. 1/8 729
Form#90L(Rev.1/83) DO NOT WRITE BELOW THIS LINE