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Address � Permit No.
Name of Oc:.upant—_^ __ _ Prrrmit charge
Connection
Paid by_--- -- -.—
- -------- --- -_—` --- Date connected-._-- _
Type of Building_ �' Inspection fee._,________.
Service Rate___- (/ G/ Paid by -___ Date-- _�
Contractor_ _ As�jessment _ ___ _ __ _--_Paid
Size oT conn,.►ionj—
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