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Date: 9/0/oi APPLICATION FOR PERMIT
C. 82 S.40 M.G.L.
DIG SAFI'. NUMBER
START DATE.
To: Head of Fire Department
City / Town
In accordance with the provisions of Chapter 148, M.G.L. as provided in Section 1 OA application is hereby made by:
Name:
Address:
Ea D Sto rmCLY
—(Full name of person, firm or corporation)
P. o. !6x 7,;7a ster-L,/23 na/9 o r I
(Street or F.O. Box) (City/Town) (Slate) (Zip Cale'
For Permission to: Si"O re ..300 L� i S . Qom' L • P• 6
State clearly the purpose for which the permit is requested: 1-1,6.1--
Location: (a) 99 /t cu-3i —
Name of competent operator if applicable:
Date Issued { } Date Rejected {- }: By:
Fee Paid { ; Fee Due { i Amount: �.
Fire Department Number
Date of. Expiration:
Applicant Signature:.
ficay tiff Conpeenc)' i : e1
f1 Applicah'c)
I■■ M 9 9 9 9 19 9 MMMMMMMMMMMMM9 M■ ■ M MMMMMMMMMMM D. 9'9 M M M C i M M• 9 9 M Q W. Y IB K 9 W 9 12 In 9 W M 9 M li 11 B 9 9 9 d• 11i M rI M 9 9 0 19 1i M 0 11 9 1 9 M
#•
Date:
r JefuvxGmere6
C. 82 S.40 M.G.L.
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frecalii)e i f`u;+>.
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PERMIT
DIG SAFI. NUMBr:k
START DATA:
In accordance with the provisions of Chapter 148, M.G.L. as provided in Section _10A this permit is granted to:
Name:
For Permission to:
State clearly the,purpose for which the permit is granted:
(Full name of person, tin, or corp4latiou;
Restrictions:
Location:
Fee Paid:
Signature and Title of Official Granting Permit:
This Permit Will Expire On:
�(THIs PERMIT MUST BE CONSPICUOUSLY POSTED UPON 1FIE PREMISES.) <_