Andes, RyanA
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Name:
Address
Permit Application
Return to: Town Clerk
Town of Wappinger
20 Middlebush Rd.
Wappingers Falls, NY 12590
c-SA� 4S
(Last)
+ (First) (MI)
V � l/► nwk J
(streetAddress)
Wappingers Falls, NY 12590
(City) (ST) (zip)
Phone: (2 [S-) 3 bs S-- .
Address of Sale: J .Mger
(If different from above) (street Address) -®�" Cit e k(
Wappingers Falls, NY 12590 �� o
(City) (ST) (zip)
Date of Sale: 41 13 From: I A,44 until 5qm
D y One) {Time Begot) (Time End)
[ 4-- From: until '5-'
ay Two) (Time Bei) (Time End)
From: until
(Day Three) (Time Begin) ("Gime End)
Sign: els .-- Date: `1 'ZO2, S�
FOR INTERNAL USE ONLY
Received by: Joseph P. Paoloni ❑
Lori McConologue ❑
Grace Robinson ❑
Date Received: I l
Serial #: