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lJ�'ILI�'Y P�RNiiT' AP��,Y�AT'��N <br />CITY OF EVERETT PERMIT' SERVICES <br />3200 CEDAR STREET, GVERE7T, NJA 98201 <br />425-257-8810 - FAX 425-257-8857 —v✓w�v.everettwa.org <br />S� �3 L e�tnN�e- (� <br />PROJEC7ADDRESS <br />Propeity Owner <br />htail Address <br />Tenanl Name Qf this is for a comn;ercial husiness) <br />City <br />Stale/Zip Phone <br />j/Je�u.�e,.5� �'n-its�iiiy ��,. ;� �OJ3ek %�(91 d i_ �ti44 ZD� %9S 7�1�1) <br />CoNractor hlailAddress City Stata/Zip Phone <br />��F�CI.���l �g`ll_,!�'� <br />'NA State Contractor Licanse Numbr.r (required) <br />Work to be done: <br />❑ Side Sewer Repair <br />❑ Side Sewer Alteration <br />❑ Side Sewer — New Installation <br />�Install Backwater Valve (outside the building) <br />O Cap off Seever <br />❑ Install Water Meter <br />CN� <br />FGV6ED H/13R014 <br />OS2-�7� <br />Ciry of fverett P.usiness License Number (required) <br />FEE <br />?7D ° a <br />�ERr�rr:r <br />U I�D�D l� <br />