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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 .
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,..,Sk~of Service Here
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Connection made in ;Street.
Remarks:
Work completed 19