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City of Tigard
INSPECTION REQUEST
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INSPECTION TWE' PERMIT NJ. :______
DVi'E ISSUED ._ I Z I
OWNERS NAME :—=----- -
ADDRESS: Z-26242
CONTRACTOR :
TEST : Air 0, WQferd, Visual Jar, Laboratory [;
RESULT: Approved , Gisdpproved O , Pending
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INSPECTOR DATE
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city of igard
INSPECTION REQUEST
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INSPE*%"#V0N TIME: MIT '
DATE: ���=�-r—'° DA"'E ISSUED
OWNERS NAME : „�-_`•�`='a� L I
ADDRESS: /,,Z6 70
CONTRACTOR
TEST : Ai' C , Wcte-X, visual , Laboratory ❑ `
RESULT: Approved Disapproved ❑ , Pendinj ❑ I
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INSPE^,i OR DATE
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ADDRESS f 7V c!- (.. �_,ti,�;,� PERMIT NO.—
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PERMIT CHARGE none
OWNER
CONNECTION FEEoz�
PAID BY � u
TYPE OF BUILDING DATE CONNECTF.
SERVICE RATE �r Cc-� �„ INSPECTION FEES
CONTRACTOR — PAID BY -DATE
SIZE OF CONNECTION Z/ ASSESSMENT �a� �. PAID
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