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-- _ -----1 <br />UTILITY PERMIT APPLICA710N <br />CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAR S�REET, EVERETT, bVA 98201 <br />425-757-88i0 - FAX 425-257-8857 - v,�vnrJ everettwa org <br />I <br />_�30 V l�g� n� to G V(�i � <br />PROJECT ADDRESS <br />' _!'/r f'c�_s��i/a I <br />iPioperty Owrer tdaa Address Gly StalelLp Phone <br />I <br />Tenant Name (II th�s u for a commercial bus�ness� <br />, <br />s� <br />Contracicr �'`a�l Atloress C �y <br />, �ri�� _��G3GJ <br />`,VA State Canlracror Lrense Number (requi•ed) <br />I <br />Work to be done: <br />i ❑ Side Sewer Repair <br />❑ Side Sewer Alteration <br />❑ Side Se�ver - New Instalialion <br />f�istall Ciackwater Valve (outside lhe building) <br />❑ Cap off Sewer <br />C' +II Water Meter <br />�- <br />S�gnature - <br />._�...;��ir�i..,.. <br />3 �7 <br />�,i:c 9�x• __ ,s�7 <br />Slale�Zip Phcne <br />� S3 �/S� _ _. <br />Gly cl Evcre�t 6usiness License Number (repuired) <br />/ S" <br />F[E � <br />200 <br />.✓ <br />PERh1ff� <br />U (��Z- D�I <br />I <br />i <br />( <br />