9575 SW LEWIS LANE-1 9575 SW LEWIS LANE
i
I j
v
q
�d
a
N
.4
3t
a
a
rn
m
Ln
t"
tn
o�
I
t
City of Tigard
INSPECTION REQUEST
for
iNSi•EC`fION TIME : _-__� ERMIT NC. : ___-
DATE--'�_� L__ DATE ISSUED
OWNERS NAME .
ADDRESS : /_ ✓:.-d �_. [s�.h -
I CONTRACTOR : - – -- - —
i
TEST' Air ❑ , Water L ;(, unl M , Laboratory [] I
!'ESt1LT. Approv+,d 1000,/Disapproved D fending p
SKETCH'
I
I �)
INSPECTOR OAT
+ + Aitach supplemental fest Jota herei]
+
1
I
t
i'
i
i
cv�
Address L
� ��_--- -�..���� - "LQ Permit No.
Name of Occupant _ Permit charge
i
Paid by —-- -- ---
- --- - -- Date connected
Inspection fee.
'Type of Building - r,ti'f�� k-p�c'L�' -_---- --_
----
Service Rate_. ;%Q -_ ;aid by -__Date__
Contractor_ _ Ass.ssmeut_______ ___Paid____
Size of connection