12255 SW TIPPITT PLACE 12255 SW TIPPETT PLACE
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ADDRESS PER IIT
PERMIT CHARGE none
OWNER f-nNNECT?DN FEE0 E
PAID BY
TYPE OF 8,1Il.DI.JGj� -� DATE CONNECTED
SERVICE RATE 105PECTION FEE
CONMACTOR PAID BY DATE
SIZE OF CUNNI=CTION ASSESSPIEN'f LAID
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City of Tigard
INSPECTION REQUEST
,for
INSPECTION TIME * _ PERMIT
i DATE: DATE ISSUED.—
OWNERS NAME ' _
ADDRESS :
I
ITEST: Ait ❑, Water Gj, Visual Lam, 'Laboratorar �,
RESULT. Approved lam; Disapproved ❑ , Psnd,i
SKETCH: _ ._._�_— _........_._.__..._.__._
IN PECTOR DATE
rNOTr A'to : jpp,n.nontu' Deft d u i L . Ri :,;