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UTILITY P�RIVIIT APF'L�CI�►TIOIV <br /> C1TY OF EVERETT PERMI� SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> 425-257-8810 - FAX 425-251-8857 —www.everettwa.org <br /> /�� 7 D�G � <br /> PROJECT ADDRESS <br /> �O�I G,✓e SG�1 it�/�S�r/ <br /> Property0vmer MailAtldress Ci�y Stale2�p Phone <br /> �O i'G G .r/G_ <br /> Tenant Name(If this is for a crnnmercial b�siness) <br /> �'a�M ,. l,.� �l r Q � kr,�cna �Pa 55�Ft Ev�%G� i.�J4 QS�o <br /> CoNrBCtor MadAddress City State2�p Phone <br /> � C�tM �B � ►� t7MS oy � � o � <br /> �VA Sta�e Contrac�or License Number(required) City of Everett Business License Number(required) <br /> Work to be done: <br /> ❑ Side Sewer Repair <br /> ❑ Side Sewer Alteration <br /> O Side Sewer — New Installation <br /> �Install Backwater Valve (outside lhe building) <br /> ❑ Cap off Sewer <br /> ❑ Install Water Meter <br /> FEE <br /> � �p.°.° <br /> N � ---- L/ �� / PERMIT� 1 <br /> Signature Date � ��D�� 1� `� <br /> REVr5E0 r fn9/:ON <br /> ``r` J <br />