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1528 WETMORE AVE 2022-05-17
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1528 WETMORE AVE 2022-05-17
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Last modified
5/17/2022 2:14:01 PM
Creation date
5/17/2022 1:58:51 PM
Metadata
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Address Document
Street Name
WETMORE AVE
Street Number
1528
Notes
BACKWATER VALVE
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� ------ ------ --�- - - - � - ----�— - - --- . . . i <br /> i <br /> . I <br /> i <br /> i <br /> � <br /> l i.If thls clalm InvoNes a veh!de a.ddenVcclllslan,piovtde your vehlde Informatlon:.__ __ — - I <br /> . � ' 7:�leNv. � Alake ' A1pdN YCnr i <br /> I <br /> LYi✓er'sh9me --'— ' lAJ�erf[lcenx:M1b• ✓rhrecOnneYs)(if0.��isrnrim,�re�«r) � <br /> OirncYi fns✓.:xam inmJuny _� -- —�� P'ronc A'o. !b6'rylla . --�— ! <br /> 12.t2ames,addicss�w and li:icplwne numhe�s ol all persons InvoWed In nr witner,lo lhis Inddent: , <br /> /J � J i <br /> L-fll.7` --'_-"' - - ----'--" _' i <br /> �--- -- -- --- � <br /> 13.Natnes,addresses and tc ephane umbcrs uf a:l City of Evcie:t employees havin^g kn�`wJ+�eclge a6out Lhls In:ldent L��,�.� � <br /> �J�l 'y ��l,C�'r_�,�,c�������_�-c�8,1,�1�1• ��L'lF2��'�J� I <br /> � v � ��Q_ i <br /> - --- --- - - -- -- --- --- -_---- -�� � ; <br /> 14. Nam�, addmsscs and tclephonc numbr.rs of all In:livlduals n�: n�rcady IJenlifled In NiZ aud til3 abov/eu��er o ha4e'knov ed � ^� I <br /> rcgarAln9 lhe Uabllity Issms luvolved In tid;'nddent, or knov+IcJye of the ClalmxnCs restllin9 dan/19e L.WOII u / �/ <br /> deuription as In Ihe naWre and rx[ent of each ieismis knowled9e. Atta[h.ddltlunul:heeLs It n:cr.ssv� <br /> � nq�s5'i i-E �/:y-cran�•_�_�.,����� _/���� � <br /> L'p�-��-�t�r-��P�,O � - '�-�-� --,-- � <br /> v�/� <br /> I5. �escri6e Me cauz oF thr In)ury ar damages. Gylain the ezten[of property loss or meAical,physical or rtiental InJudes. Attadi � <br /> additronal shcets If ncws�ry. ' <br /> ��2 u)ar�'�s�m�iv��fo �,�rai n behi►�`1�c1a5���'? <br /> ast.�pxc!'a���1►�_SY�u]er i►2 2rt�2�• ��n-�_ o� in� <br /> ru�_.n�ll,�s�El��e�'_�c��ik� P ea4�._ o,re u-� u f�kSso <br /> � <br /> a�Ci'lq�1D�e��_ ��-^cl; - �a��� �' �`"/�'xrd_��oula re <br /> i5 � ����- � � sc ��►� __._ __.__ . <br /> f6.I)as lll Inddenl hec poded to law enforcement,sifety a�sttwiry personncl? If so,whc and lo whnm7 ' <br /> /-C-�-� .. ------- ------------- --- ---- I <br /> 17.Nanres,addmsses and lehphona numbers of trealing m�Icai prrnlders. Allach coples o(all meAical repads anA blllinys. <br /> tn.i��c,scatta��ao�imen�tn,ts.��porcu,cdau,�'saiic�ations. � � htJt.a� I�CCC/� �� <br /> ��/'P..�1�l,��('�� (R�,PJ� �"��,(J�ci '�- 9�- <br /> 19.I clalm dama9c:fium Ihe CJty of Everett In Uie ium of$r L � `�' <br /> 7JY��p'zz- .JJ D �¢- <br /> Thls cJaN yfp rm iy,�t���sig�c tl�r�j c�C numt"y�o dJ.,nf,t�c O IQy q[ µJ�,��9' �i ho ��t �o, cr� � <br /> �llodjq�lnF Ihe�lalfi•.6q19lfr-f��c'V-eR' �llnti ��GCtlfFirt t�e3!btL.�Wa3n t, , u �d�an /���/ <br /> ge��n a��� 5����j�,Q�(� �� �7�t`C�! NQ <br /> [dedare under penalty of peijury wder lhc laws of the State of VJashingLnn Ihat the forcgcing L•Ime.and m�rect. � <br /> �,��.1��� / � <br /> rr��_� a�t 3_�.�- l�c�sd. <br /> Signature of Claiman[ U� te Placosigned (ci and state) <br /> Rov.07/08 <br /> O �'" <br />
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