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State of Wisconsin INSPECTION <br /> Department of Commerce <br /> Safety&Buildings Division REPORT <br /> Bureau of Field Operations <br /> Inspection Date <br /> Personal information you provide may be used for secondary purposes[Privacy Law,s.15.04(1)(m)). <br /> Name of Premises Address or Legal DescriptionCit wns_hip County <br /> 72 <br /> Master Plumber Name and Address Master Plumber Firm Name and Address Plan I.D.No. <br /> Sanitary Permit No. <br /> Journeyman Plumber/Soil Tester Licensed Person's Name(s)and License Number(s) <br /> Owner's Name and Address <br /> OV <br /> Ile <br /> !� � ���'i�' �°� �il'�� G ,G�i'�sl��-� ,mss �s•�r li;��' ��— <br /> Page of Signature of Responsible Licensed Person(only one needed) <br /> -17 <br /> Check all <br /> 1 Sign r f Plu n on t/P ' wage Consultant <br /> Original: Copies to: �thatapply� <br /> sao-6192(R.12/9e) District 0 S&B D Plumber ❑Owner n County/L Insp. 0 Other <br />