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Addreu ,/ � f , 'Z/ I I-ormit NO.--------
Name
O.__—_____Name of Cccupant`L J i &44 a. ,� ,r Permit charge
Connection fee_ r'• D U
Paid by
Date connected ''��'� J 7
Type o' Building � _ Inspection
Seivi,.e Hate_.• l-' Paid by
Contractor _ Assessment O Paid--
Size
aid_____.Size of connection