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_ __ ____ _ ____ ____ _____ ____ _ ___ __ ___ ____i <br /> � . <br /> � • �TIB�lT� ��R11�1�' �F'PLICAl"I�N <br /> i C�ITlf QF EVERE7T P�EF2MIT SERVICES <br /> I 3200 CED/�R STRGET, EVE:RETT, WA 98201 <br /> I 425-257-8810 - FAX 425-257-8857 -www everettwa.org <br /> � <br /> � <br /> _._ �l �3ar k�� ---— -- - <br /> PROJECT ADDRESS <br /> ---- '� -�`-1'1�K•K_��l�. --- -_�iF�1- -- <br /> Property Owner (dail Addre,s Ctly Sia!e/7ip Pttone <br /> I <br /> Tenant Name (If Ihre is(or a commercial bus�ness) <br /> �"/�c."�//Ci t�/u.nd�n �/07 7I�A�eL✓_� MaiySv�i/G_w/�- ���i .i37'�s� <br /> COnlydctor ' MaJ Address City State2ip Phone <br /> /�/�oGLPG Qo3�7� �3�iss <br /> WA Slate Contra tc or License Numher (required) City o(Fverett �usiness License Number (required) <br /> Work to be done: <br /> ❑ Side Sewer Repair <br /> ❑ Side Sewer Alteration <br /> ❑ Side Sewer - New Installation <br /> �Install [3ackwater Valve (outside the building) <br /> ❑ Cap of( Sewcr <br /> ❑ Install Water Meter ----- <br /> F[E <br /> ��jD ,00 <br /> -__�j 3� / . PERMITN <br /> S�gnalure --� '- Dat � �/D����� <br /> v, <br /> {:B'ISlO I Ir�9R0�J <br />