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Location
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Address
Name.
Kind of Pipe
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Date Material Adlount Total Date Amount
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Labor
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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 $_
Owner
Address
Builder _
19
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e in Street.Work completed
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Connection mad
Remarks: