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���Ilnl�"� ��F��111T ,i��R�l(��4�1��1 <br />�!�'`t �F E�JERET3' f�ERMI� SE3Z�/I�E� <br />3200 CGUAR STREET, EVERETT, WA 98201 <br />425-257-8810 - FAX 425-257-8857 — v�nvw.everettv�a.org <br />.� GI // Lo//� 1i <br />J <br />PROJECT ADDRESS <br />_�G�rll,� %Y�/2�,r+=//Csi7 <br />Property Owner Nail ACdress City State2ip Phone <br />Tenant Name (If this is for a commercial business) <br />,�i'�o/IU P/u✓�l3' <br />Contractor <br />Address <br />/� ��� G r'G �03 Lr <br />VJA State Contrador License Number (required) <br />Work to be done: <br />❑ Side Sewer Repair <br />❑ 5ide Sewer Alteration <br />❑ Side Sewer — New Installation <br />City <br />�Install Backwaier Valve (outside the building) <br />❑ Cap off Sewer <br />❑ Install Water Meter <br />v, �i � <br />S;ate2ip <br />Phone <br />oS3�/s.r <br />City o( Everelt Business License Number (required) <br />FEE <br />�3�00 <br />PERMII"� <br />11)503 - I0� <br />�:c Y15E0 i 1/19/]010 <br />� <br />