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PERMIT TO CONNECT
City of Tigard
Permit N(� X5)3 DATE
PERMIT 15 GIVEN TO_l I LAVI-*..--. `P 1.w« J"o
OF._.f►�.��,�,Wit.__1..i l�_—��.il.t_._��5_�I ftl�.L�.�f lAnr/..�'�E�_..�,,,,. _
TO CONNECT A __—` ffi/ S_•' '. __ _ - a
TO THE SYSTEM OF CITY OF TIGARD i
THIS PFRfAIT MUST BE POSTED ON THE DESCRISED PREMISES UNTIL CON.
NECTION 15 MADE AND INSPECTION OF CONNECTION WAS SEEN COMPLETED.
PERMIT FEE PAID $ CITY A�F/TIGARD
CONNECTION INSPECTED AND APPROVED
DIIto Superintendent
Address/— Permit No.
Name of Occupant________ Permit charge
Connection fee-?
----------__ Paid
Date connected
Type of Building Inspection
Service Rate Paid by _ Date
Contractor Assessment-_. . Paid
Size of connection