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UTILITY PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEIJAR STREET, EVERETT, WA 98201 <br /> 425-257-8810 - FAX 425-257-8857 - wv,�w everetlwa.org <br /> i S ��-I �e�-t-, �,n-- F�� <br /> PROJECT ADDRESS <br /> �12 S <br /> �-uS � � v�n(pn �5��-I �-�d�w� ��e/r� �" S8ZG1 �S� v3� <br /> PrOpCrtyOvrner �^adA�ldress City State.7.ip Phore <br /> Tenant Name (I(Ihis is for a commercial business) <br /> 1'1� ���.nl�: �75�5 �/rySr• SL`� Sn���'sl G.,fs ��z4� Y?S �6o,t's�o <br /> ConiraUor !dad Admess Gly Sta;e2p Phone <br /> ' 3 <br /> � i�,v� (���x � 3�U - -- d S � <br /> WA Stale Contrar.ter llcense Nurnher(requ�ietl) City of�verett Business License Number (requ�red) <br /> Work to be done: <br /> � Side Sewer Repair <br /> O Side Sewer Alteration <br /> ❑ Side Sewer -- New Installahon <br /> � Install Backwater Valve (outside ihe building) <br /> O Cap off Sewer <br /> ❑ Install Water Meter <br /> FEE <br /> 3o cO <br /> G<"✓ '�/� �-�IC'- I S PERMfTk <br /> Signalure Dafe � 15 0 2 - 03 � <br /> RE�bE011/19001C <br />