12110 SW 92ND AVENUE FA W64 wl
- 12110 SW 92ND AE,NT IP; -
I
Q)
c
Q)
v
C
N
O�
3
rJ
i
I
Address_ _� a4,--P, Permit
Name of Occupant_ _ Permit charge `
Conneciion fee.._
---- ----- — -- Paid by
- - -------- - -- Date connected
Type of Building-J1
—._ _ Inspection
Service Rate.----2 " ,2 Paid by
Contractor _ -6UL .f l /✓�(�.L Assessment__ Paid
Size of connection--