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AmountMaterialDate-
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DATE ¥.9 W •
TOWN OF LEXINGTON -BOARD OF PUBLIC WORKS
WATER DIVISION
The undersigned applies fot'a supply of water at No.$/~~~and hereby agr€es to
cumply with the l'ules and ngulations as now,or at any future time,established by the Board of Selectmen.
Am't.of Estimate $
Am't.Paid S ~!f-!};;;
Bllilder~--:J"~
Owner
Adctress
Sketch of Service Here
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Connection made in
Remarks;
_____________Street.Work completed _19 •