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RECORD OF SEWER AND WATER DISCONNECTIONS
Date 04029
Address of Building /2oz , 17e_
Name of Owner �� p� / �/
Address of Owner / 4ir,4 cam. —
.. ne SG 19 ' by 4!.,, ft c
Wa - s _ . , - : _ - ro r ty Line -l/ 19 by 411 _ ' %
No sewer and water services to premises.
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 lumber on or before ,
0,v a � ,. Lc Owner ' - -- ' _ent
Approv d for issuance of wrecking or moving permit.
.. ,2,/ _
Date ' . , �
'1 tubing Inspector