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�I�0���1 �( 1������0� �����C��ll� ���l" <br /> �B�'a�P 3�� �@���d��'�� ����0 tl 5��@�8�[�� <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> 425-?_57-8810 - FAX 425-257-8857 —www.everett�va.ory <br /> ��oZ �.L�v.�k-e.�� <br /> PROJECT ADDRESS <br /> ��,��� IJQ ��'�IPi� �'l� <br /> PropertyOwne� Idai�Address City State2�p Phone <br /> Tenart Name(I!Ihis is for a commerciai business) <br /> �av�l�z�c � � ud��;�n� �P� 55� � E,�:z� i,�� R��%(O <br /> Conlractor tviadAddress Cl,y Statellip Phone <br /> � � � � � � � 7 � � � <br /> I�VA State Conirector License Number(requirzd) Cily of Everett Business Lcense Number(required) <br /> Wark to be done: <br /> ❑ £ide Sewer Repair <br /> ❑ Side Sewer Alteration <br /> ❑ Side Sewer — New Instaliation <br /> Install [3ackwater Valve (outside the building) <br /> ❑ Cap off Sewer <br /> ❑ Install Water Meter <br /> f-EE <br /> /� � � Q , <br /> 30 °° <br /> �"� i v✓Fu�/` �' ��'h� ��� /�5 PERh1ITit <br /> `` oate <br /> SignaWre ./ 1 � I (�O� _ O�� <br /> �L ;J <br /> FEVISED I V�o/10f f <br />