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Address_L��.�L_�� Permit No.
Name of Occupant _ Permit charge._ .. —
��✓1_ C ll'riL�G� Connection fee_ _lj,2 �
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Date connected--,
Type of Building __ Inspection fee -_------ ._--
Service Rate__2 Q ✓ __ Paid by -_ - -__ Date___^ —
Contractor_I L _ Assessment__ . _ Paid
Size of connection-__14L", -