12040 SW 116TH AVENUE-1 W 1;;;1a,,,,,�. U ,l LJ Lel a,,,� ,L1 'i 'f
12040 SW 116TH AVENUE
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PERMIT TO CONNECT
City of Tigard
Permit No S63 DATELr C Cl:.- r ,L
PERMIT IB GIVEN TO
OF
10 CONNECT A Z
TO THk. SYSTEM OF CITY OF TIGARD
AT-
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THIS PERMIT MUST BE POSTED ON THE DESCRIBED PREMISES UNTIL CON-
NECTION IS MADE AND INSPECTIO14 OF CONNECTION HAS BEEN COMPLETED.
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PERMIT FEE PAID $ ____.CITY OF TIGARD
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CONNECTION INSPECTED AND APPROVED
Dale SYprrirahlnliMf
Address Permit No. 3
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Name of Occupant _ Permit charge
Connection fee--------
Paid
ee--__ __-
Paid by —-- _.�-----
- --- . ---- — - ---- - - Date connected _—
Type of Building._-_—___._____- Inspection fee___..__.
Service Rate _----------_----- Paid by - Date---
Contractor
ate -_Contractor _-- _- _-- Aatessment----- -------Pafd____._
Size of connection
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