11590 SW 95TH AVENUE-1 -- 11590 SW 95TH AVENUE --
r�.
v
a
C
D
d
u
Ln
T
3
O
Q�
�r
J!
Address _ _--Akli Permit No. Y
Name of Occupant____________ Permit charge
Paid by __
----.�—._ -- - –---__..._-_ ----- --- ---- Date connected
Type of Building ! ------- Inspection fee
Service Rate — ,2. - -- Paid by ___Date__,_
Cc-►tractor
Size of connection-
__