HomeMy WebLinkAboutWORK ORDER - 04-00338 - 614 Cook St - New SFRAPPLICATION FOR REXBURG CITY SERVICE
NAME %,Pf-t/T /1-62ae / 1
ADDRESS S� y /t/• ASO �• ^ 6�
PLUMBER-
PROPERTY
LUMBER PROPERTY OWNER 7�,Z�Eit/T �1zei1'
WATER SERVICE:
Water Connect......
$
Water Meter .......
$
Meier Box .........$
Ring & Lid.........
$
Curb Stop .........$
Setter ..............
$
Sewer Connect .....
$
TOTAL ............
$
Size
In City Out of City
Storm Drains — $
APPROVED BY
WORK ORDER
ACC# _ RT# PHONE EFFECTIVE DATE
NAME S SERVICE ADDRESS
MAILING ADDRESS oj/ -2 SZ G
OWNER ,T A&geeLS PHONE 3J1-7RS
ADDRESS
EMPLOYER OR RELATIVE
COMMENTS
SS# _)17__
SIGNATURE
IN
❑ READ
❑ ON
❑ RE -READ
❑ OUT
❑ CHECK LEAK
❑ OFF
❑ WTR.SWR ONLY
❑ VACANT
❑ GR CONT. # _
METER SIZE3�
GR RT# _
LOCATION
COMPLETED BY
❑ BUYING
❑ SELLING
❑ OWNER
❑ BL CONT. #
DATE
NO. OF PEOPLE
WORKPHONE
DEPOSIT AMOUNT
DATE PAID IN
REFUND DATE _
AMT. REFUNDED
AMT. APP. BILL
BIN SIZE N0, OF BINS
ISSUED BY
❑ COMPUTER TILE