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RECORD OF SEWER. AND WATER DISCONNECTIONS
Date f~~/FO
Address of Building :3 (,0 5: ~ ~ Iff> r
, -
Name of Owner /l1/'K-e SI r V r K ~ r
i
Address of Owner
S- ~ r;-~ /c:;v/(
Sew5.r Sealed ~ JJl ~ 1 T T;r :b.i:ao-
~/)?Z';19_bY
, /
W ~i(Z;;//n~~t~d i~:~, ~ ~l~j~;: ' 19_by
No sewer and water serv~ces to premises. c=J
I, the undersigned, owner or agent of the above described property,
agree that all sewer and water services will be disconnected and
sealed by a master plumber on or befor~~~ ~A
(~ f
wa~~.d
.L,-
Approved for lseuance
v?{ /pz;
De te /
of wrecking or moving permit. ~
??~
Plumbing Inspector