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t � <br /> ��'AL�BT`� ��I��I�' ���P�I�:A�9�6� <br /> CITY �F E�/EF2ETT' i'�RMIT �E6ZViCE� <br /> 3200 CEDAR STREET, EVERETT, VI�A 98201 <br /> 425-257-8810 - FAX 42E-257-8857 -www.everettwa.org <br /> ,���. 6 ncc�ke-� <br /> PROJECT ADDRESS <br /> �XL/� /7l ci� <br /> Property Ovmer Maii ACdress Ci,y State2ip Phon_ <br /> Tenant Name Qf this is for a commercial business) <br /> �'/GII�� � <br /> ' 1�%c��13'�y 5`/'7 7/ <ruN� rr � r5v,�i� w/1- 9fs�7�i 3S,s7�/So7 <br /> ConiraCtor L1a�l Address � Gty State2ip Phone <br /> �f GL G/'L �G.�G7 GS.3�/S.f <br /> V�'A State Contractor License Number(reauired) City of Evemtt Business License Number(required) <br /> Work to be done: <br /> ❑ Side Sewer Repair <br /> ❑ Side Sewer Aiteration <br /> O Side Sewer — Ne�v Inslallation <br /> �Install Qackwater Valve (outside the building) <br /> ❑ Cap off Sewer <br /> � ❑ Install Water Meter <br /> FEE � <br /> 30 �, <br /> — -. �// f,j//� P[RMIT# <br /> Signature , Oate � � G O L� O �I <br /> J � <br /> aEV15Eo f 1r19?Ol a <br />