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I� � VILR N�`� (���r���`�' /��'�'�il�/�`�o�b�9 <br />�ITY �F EVERET`i PERfVII`l� SER�/IC�� <br />3200 CEDAR STREET, EVERETT, �P1A 982U1 <br />425-257-8810 - FAX 425-257-8857 — vwNw.everettwa.org <br />.2$ 0 3 ���+ u sT Cvc�v�- �..� . 9�� 20 / <br />PROJECT ADDRESS <br />���03 I`f f" s � EVC.�,2�.-rr <br />Property Ov+ner P+1ail Address Ciiy <br />Tenant Name Qf Ihis is for a commercial business) <br />� _ 94�3 <br />StalelZip Phone <br />2ou <br />4-E��o P(..�� n.,�ti�ce �.c.c �o E3o X�87 40.�0 , w,•i . 5'�z9, �� _o� 2� <br />Contraclor P:tadAddress City StalelZ�p Phone <br />�# l�C�.nPPCB(o3 �� <br />WA State Contractor License Number (required) <br />�Nork to be done: <br />❑ Side Sewer Repair <br />❑ Side Sewer Alferation <br />❑ Side Sewer — New Installation <br />� Install [3ackwater Valve (outside the building) <br />❑ Cap off Sewer <br />❑ Install Water Meter <br />re <br />REVISED I1/19R0/J <br />�_(`7- /S <br />6'S 3 s 3 S— <br />City of Everett Business License Number (required) <br />FEE <br />�0 °o <br />PERMITn <br />U � SOZ �05 Z <br />