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�������� ������ ����i��-���� <br /> GI'�� C�F �b'CRE i i' f���:�l11T S���f9�E� <br /> 3200 CEDAR STRGET, EVERETT, WA 98201 <br /> 425-257-8810 -. FAX �125-257-8857 —www.everettwa.org <br /> ��31 �o�n'��,.�� ��e� Y� q�6l,c�l <br /> PROJECT ADpRESS <br /> 1�,�,u�, 5�:,��, ��3i �a,��,�� fl�� �-,�z�_� ��6�� � s-Z � DY� <br /> Property Owne� f,4ail Address City Statc/Zip Phonc <br /> Tenant Name (If lhis is for a commercial business) <br /> �"/�o/% �'�%rti�I3 n 9 S`/'7 7/�.,'�� ✓-= r���S v,ii� w/i l�8�7� ��7-/S�7 <br /> � <br /> Contraclor I�lail Address � City State2ip Phone <br /> /fif�GGr'G �o3�i aS3�iss <br /> WA Staie Contraclor License Number(requ red) City of Everett 8usiness License�'umber (required) <br /> Work to be done: <br /> ❑ Side Sevder Repair <br /> ❑ Side Sewer Alteration <br /> ❑ Side Sewer — New insiallation , <br /> I <br /> G�Install E3ackwater Valve (outside the building) � <br /> . i <br /> ❑ Cap off Sewer <br /> ❑ Install Water Meter �E - I <br /> � 30vb ' <br /> ._. PFRMIT# r <br /> � Signature Dafe --- �� ( �O �-0 4� <br /> I <br /> -------. - _ I <br /> l?rV15EDff/fY10f0 "_" _ I <br /> ______��__ _'________.-____"_.__. .____"_- .__-. __ <br /> I <br />