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Date Material Amount
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DATE -
TOWN OF LEXINGTON -BOARD OF PUBLIC WORKS
WATER DIVISION
The undersigned applies for a supply of water at No St.and hereby agrees to
comply with the rules and regulations as now,or at any future time,established by the Board of Selectmen.
AIn't of Estimate $.
Am't Paid $..
Builder ..
Owner .
Address .
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Sketch of Service Here
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Connection made in Street.,
Remarks:
Work completed ;19