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# J02� '
CITY OF FRIDLEY
UTILITY LINE REPAI /RELOCATION SPECTION RE�UEST
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J�r Adrnss: �ate.
Owner. � vc ��i n
Legal �a No. eiock naan+o� �
Description io � ,� 0 �`� Ji �U / / ,� , oi Q�7' '
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Piumbin Co.: �+�►�.s u u� n„ Master Lic. #
1 agree to call for inspections after uncovering the damaged line, before any repairs
are made, an�ag�in when the�paic.is�nade but before recovering the line.
INSPECTION FEE
Water Line ❑ Sewer Line�( Repair ❑ Relxation ❑
Fee: Fee: �5 - U� Per Chapter 206, Fridley City Code
Total: �� • �Q Receipt # �� a
INSPECTION RESULT
Approved ❑ Denied ❑ Comments
Inspector:
White Copy—Inspection Dept. • Yelbw (',opy—Plumbing Co. • Hard Capy—Water Dept.