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PERMIT TO CONNECT
City of Tigard °
Permit 'NI) 500 DATE
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TO CCINNEC'f A
TO THF. SYSTEM OF CITY OF TIGAR.D
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TI-115 PERMIT MUST BE POSTED ON THE DESCRIBED PREMISES UNTIL COW
NFCTION IS MADE AND INSPECT':,N OF CONNECTION HAS BEEN COMPLETED.
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PERMIT FEE PAID ; ._y_ _---- •— CITY OF TIGARD
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CONNECTION INSPECTED AND APPROVED
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Date ;uperinfendent
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Address 117AC) �J-W 7f4 Permit No.
Name of Occupi,nt—__ ______ Permit charge
Connection fee 2.J G
Paid
Date connected
Type of Building–_ Inspectira fee
SPTViCe Rite`___-___ Paid by Date
Contractor Asuep-,nentPaid
-
Size of connection