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Address�.7�s-s __- Permit No. ��_
Name o: Occupant__ Permit chaige
----._-.-------------- __.�_ Connection fee_4�c) ---- --
_ ___._..------- ----- Pard by ---- - -- _— -- �.._
- -- - - - - - _ . - - - - D,jte connected
Aype of Building _ _- - - -_ Lispection fee 10
Servzce Rate-_-- -- _ --._---- Haid b
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Contra-tor Assessment Pais?
Size of connection
PERMIT TO CONNECT
CRY of Tigars!
Perim►►1t M DATE
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PERMIT IS GIVEN
TO CONFECT A ,
TO THE SYSTEM OF CITY OF TIGARD
THIS P RM17''MUST 13E POSTED O�' T?!•!E DISCRI13ED PRE"
ES UNTIL CON.Nro-TION IS MADE AND INSPEC7I0N OF CONNECTION HAS BEEN COMPLETED,
PERMIT FEE PAID ; _- CITY OF TIGARD
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CONNECTION INSPECTED AND APPROVED
Date Superintende;a
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