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CITY OF FRIDLEY
UTILITY LINE REPAIR/RELOCATION INSPECTION REt�UEST
.Job Address: �� 7� �� d S� • ��• Date: �� l� I
Owner: �a �M. �/ �o.�V t��2-` ��'1 `'7
L@9a� Lot No. Block Adr�' ''an
Description =� y_j �' ` �� ��- f` P�� ��
Plumbing Co.:__1_'3 �"��� 5�1 �O� ��o.�n Master Lic. #aa Q � MD
I agree to cali for inspections after unc�vering the damaged line, before any repairs
are made, an�.a�ain when the repair is t before recovering the line.
� INSPECTION FEE
Water Line� Sewer Line ❑ Repair� Relocation ❑
Fee: �� �� Fee: Per Chapter 206, Fridley City Code
Totat: �� ��G� Receipt #`� ��� a
INSPECTION RESULT
Approved ❑ Denied 0 Comments
Inspector: Date:
Whfte Copy—Inspeclion Dept. • Yellow Copy—Plumbing Co. • Hard Copy—Water Dept.
9
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#
CITY OF FRIDLEY
UTILITY LINE REPAIR/RELOCATION INSPECTION REGIUEST
Job Address: Date:
Owner:
Legal �� No. 81ock Addition
Description
Plumbing Co.: Master Lic. #
I agree to call for inspections after uncovering the damaged line, before any repairs
are made, and again when the repair is made but before recovering the line.
Signature:
INSPECTION FEE
Water Line � Sewer Line � Repair � Relocation �
Fee: Fee: Per Chapter 206, Fridley City Code
Total: Receipt #
INSPECTION RESULT
Approved � Denied ❑ Comments
Inspector: Date: ���`5���.%
White Copy—Inspection ept. • Yellow Copy—Plumbing Co. • Hard Copy—Water Dept.