11735 SW 98TH AVENUE M,
�.._ 11735 5,,, 8`13 AVENUE
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City of Tigard
INSPECTION REQUEST
for
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INSPECTION TIME :..,i— PERMIT NO. :
DATE '. �' l/yl7.I DATE ISSUED:
I OWNERS NAME .- 'Z�a-�-�L
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ADDRESS * —X13-=`
CONTRACTOR --
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TEST. Air ❑, Water p , Visual FT, aboratory []
RESULT. Approved Er, Disapproved D Pending L,
SKETCH'
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INSPECTOR LATE
COTE : Attach supplemental teat data neret:01
Address 11735 S.W. g6th _'kve. Permit No. 460d I
Permit charge
Owner Reino Koski Connection fee ---, 300
Paid by
Type of building Aesidence Date connected
Service rate 3.UU py' month Inspection fee i5
Contractor Paid by �e Date
Size of connection 411 r �� ___ Assessment Paid