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UTILITY PERMIT APPLICATIQN <br />CITY OF EVERETT PERMIT SERVICES <br />3200 C[DAR STREET, EVERETT, �VA 98201 <br />425-257-8810 - FAX 425-257-8857 — www.everettwa.org <br />.5' S .�S �a 11,� �,�� <br />PROJECT ADDRESS <br />SJ�� <br />Owner <br />SS2S <br />A7ad Add•cs's <br />ienant Name p( this is for a commercial business) <br />,Mue.� �1�,�� <br />Comractor <br />' IJSlS�/Ijs'SrS�.% 5r+ <br />A1a�l Adtlress <br />Crty <br />M � �,� r�n� ��3 T� _ <br />4VA State Conlraclor License Nurnber (requhed) <br />Work to be done: <br />O Side Sewer Repair <br />❑ Side Sewer Alteration <br />O Side Sewer - New Installation <br />� Install Backwater Valve (outside the building) <br />❑ Cap off Sewer <br />❑ Install Water Meter <br />� �-- � - 2Y-� <br />Signature Uate <br />!+c��sEn tvtopJi. <br />Cdy <br />� <br />SlaleiZ�P <br />Phon2 <br />y2S 3fs <br />�9�b' <br />S- 760 • b-IC� <br />Phone <br />OS3�3S <br />Cdy ol E-veretl �usiness License Number (required) <br />FEE <br />� � O� <br />� <br />PERh1CT# <br />u15�z-��5 <br />