11730 SW 95TH AVENUE -��W I
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Address �,�—C(/U'� PermitNo.
Name of Occupant Permit charge _
Paid by _�-----___--
Date connected
iype of Building _ Inspection
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Service Rate__ ��, p fj Paid by _-Date----
Contractor
ate __Contractor _ Assessment14-79',40 Paid S _
Size of connection