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������� ������ ����������� <br /> GI�'�f f�E= �VFRE E T" f��t�ft�IT S��lfI�E� <br /> 3200 CEDAR STREET, EVERETT, VVA 98201 <br /> 425-257-8810 - �AX 425-257-8857 —v,�n�w.everettwa.org <br /> I <br /> i��v- c���� a�� <br /> PROJECT ADDRESS <br /> �l�in�ar► C��h� _ ��.�-� �,��- G g�c�l <br /> Proper�y Owher ���ail ACdress Ciry Statel2ip Phone <br /> Tenant Name(If this is for a commercial business) <br /> �"f�c.//� t�%c�17�'��S `/J 7/l A�� i✓i: r�u�ySv,ii� w/?� l��s��� 3Fs7�/Sa7 <br /> ConVzctor IJ�ailAddress � City StalelZip Phone <br /> �fGGG PG �G.�G% GS.3�/SS <br /> WA State Contractor Lir.ense Number(required) City of Everett Business License A'umber(required) <br /> Work to be done: <br /> ❑ Side Sewer Repair <br /> ❑ Side Sewer Alteration <br /> ❑ Side Sewer — New Installation <br /> �Install Backwater Valve (outside ihe building) i <br /> I <br /> ❑ Cap off Sewer <br /> ❑ Install INater Meter <br /> FEE <br /> �3D.°� <br /> �. l!�— I —/,� PERMIT# <br /> Signature Datc � � I �D/_ _OO� <br /> lD <br /> RpV15E0 1f/�BRJIa . <br />