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AEGORD OF SEWEE AND WATER DISCONNECTIONS
Date ����/��
Address of Building_��� � �
Name of Owne r
Address of Owner
Sewer S�aled at Property Line 19�by o��DY'��� Cs-�
Water Disconnected at Property Line 19 by ^
No sewer and water services to lit/C l � ��4�C�'� � ��'
premises. �
fT- �e�� ��'� z�:��� L7uJ,����
I, the undersigned, owner or agent of the above described property,
agree that all sewer and xater servic�s will be disconnected and
sealed by a master plumber on or before
Owner Agent
Approved for s$uance of w_recking or muvi t�
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