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Si1�i.iiT E\`iD::�iCr TFL'!T ��lil?„?E:JT <br /> CO.`.?PLI�.S \':iT:: '1'HE ST'1_�D.yl'.�5 p=' <br /> T:� UNii:R:'�RITERS' LAL'UI:ATORY. <br /> IIv5?rCTION UT' S1GN RFQUIRED <br /> ;;�FO_^.E £RLCTION. ' <br /> CALL 259-8i15 I'OR INSPECTION, <br /> � ' <br /> � Date � / 17/'r <br /> • APPLICATIO:V I'OR ; i �st- 11 c'r,u';1 -- f,iee i �t�rior i i lu �i <br /> ; ion � l ,s- i �� sl , , ' . ' _ i ` c (all cn ori :at,= prop�rt:� ) . — <br /> 1 <br /> , Tl:� uadersi�ned owaer hereb}• aerees to hold and szve }iarmlr.ss the C:tv <br /> of icereit frem any ar.d ali clzims fcr damages that r.,ay a:ise hecause of <br /> installation o: the improveinent he:eto aaalied for, �nc; fur!ner agrees to <br /> r^mu��e same upen notice irom the City and to :eaiace a":1 p��blic property <br /> dar.-iaged the:eby. <br /> � VnLUE: � , - _.. <br /> CIRCUITS: - � � i 1 �� <br /> { <br /> , <br /> ` . <br /> E <br /> t <br /> � . . . <br /> / <br /> Si ned � ��Al� U/Si� �N �e;7 �t[C� ,61 /��/`/" � Owaer <br /> � � . <br /> �/i1' -�i�; C�' -�-'� �'����•� � /K�c � Contractor <br /> � � � � � �/�.�- <br /> . <br /> B��� �t��r-l�- �. ►C . - VL . c . �/13/i �r ' <br />