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UTYLV`�� ��Rii�V`� A�fPV�V�ATY�i� <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETf, WA 98201 <br /> 425-257-6810 - FAX 425-257-8857—�.wvw.everettwa.org <br /> �� �O i�a.��p �I�1tQ . <br /> PROJECT ADDRESS <br /> /'1 �� S sPn .�m1 <br /> Pro yOwner MailAddress City State2ip Phone <br /> Tenant Name pi this is for a commercial business) <br /> [NPI�� C,�,s�r��'�. � /�31�� /y9/ �Ion/n2 /�J�l 2� 713 7��-� l <br /> CoNraclor Mail Address Ciry StatefLip Phone <br /> �v E� w�c-c_ �y �.in DsZv�� � <br /> WA F.ate Conlractor License Num6er(required) City of Everetl Business License Number(required) <br /> Work to be done: <br /> O Side Sewer Repair <br /> ❑ Side Sewer Alteration <br /> ❑ Side Sewer— New Installation <br /> � Install Backwater Valve outside the building) <br /> ❑ Cap c,rf Sewer <br /> ❑ Install Water Meter <br /> FEE <br /> � 30� <br /> _ L Z� s PERMIT# <br /> � natu2 �ate <br /> U /5�'�'9 <br /> Intv�seo rvisr.m� <br />