12530 SW BROOKSIDE AVENUE P
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Address/,Z%U_0ZA)' Permit No.
Name of Occupant Permit charge
Connection fee
Paid by
Date connected C9 G,,7
Type of Buildaing__ Inspection fee__
Service Rate Paid by --Date
Contractor Asp3ssment --Paid
Size of connection
PERMIT TO CONN'6--'CT 00.
City of Tigard 6e
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Permit N() i DATE A 6
PERMIT IS GIVEN To
TO CONVECT A.
TO THE SYSTEM OF: CITY O.P. 7160 RD
AT-
THIS PERMIT MUST BE POSTk 1) ON Is HE DESCRIBED PRNMISIS UNTIL CON.
NECTiON IS MADE AND INSOLi" FN 01-* CONNECTION HAS ORIN COMPLETED.
PERMIT FEE PAID $ CITY or TIGARD
BY,
CONNECTION INSPECTED AND APPROVED
61-0
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