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Date Material Amount Tot~l ,Date 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.
Am't.of Estimate $_
Am't.Paid $_
Builder _
Owner
Address
Sketch of Service Here
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Connection made in Street.
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Work completed _19 .~