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CITY OF FRIDLEY
UTILITY LINE REPAIR/RELOCATION INSPECTION REQUEST
Job Address: �"'�3� ��'A� Date: �- 3�'°1�
Owner. �\� ��i.ti\�E..-
Legal � No. Blxk �t�o�
Description C%/D -� I / � �i�� � �`� , »)_��°, ,L �,,.a-a� �(
mbin o. ��� -��«- Master Lic. #�
I agree to �r inspe�t' ns after uncovering the damaged line, before any repairs
are.�ade, an `altrwh air is made but before recovering the line.
Signature�Z �``'�-
INSPECTION FEE
Water Line ❑ Sewer Line j� Repair� Relocation �
Fee: Fee: � Per Chapter 206, Fridley City Code
Total: Receipt #
INSPECTION RESULT
Approved ❑ Denied O Comments
Inspector: Date:
White Copy—Inspeccion Dept. • Yellow Copy—Plumbing Co. • Hard Copy Water Dept.
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CITY OF FRIDLEY
UTILITY LINE REPAIR/RELOCATION INSPECTION REQUEST
Job Address: � 33 1`�� \�� Date:
Owner.
Legal I �a r,o. I e�«k Addifion
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
�� n
Approved� Denied ❑ Comments ._�i �r
' � i�l . �
Inspector: � Date:
White Copy I spection Dept. • low Copy—Plumbing Co. • Hard Copy—Water Dept.