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I <br />IJilLlil� PERIVII`� APPL������N <br />CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />425-257-8810 - FAX 425-257-8857 — www.everettwa.org <br />� JZ �3 L a��� �2 x-c:;� �j �� <br />PROJECT ADDRESS <br />���� v ��t J'�1 P��e,f : hC.t �� -� ►" i 5 2�� � c>>v� bcvf c/ ,�'i�� �,;�rC-i i <br />Property Owner�1 Mail Address City Sta <br />Tenant Name (If this is for a commercial business) <br />- � ��4 i - :� � r �;� � ���_ <br />Contractor Mail Address <br />._ ____ _._-------- <br />WA State Contractor Li�ense �Vui�iber (z�auired) <br />Work to be done: <br />�J Side Sewer Repair <br />❑ Side Sewer Alteration <br />❑ Side Sewer — New Installation <br />❑ Install Backwater Valve (outside the building) <br />❑ Cap off Sewer <br />❑ Install Water Meter <br />- <br />� <br />!,J .. �.. \� � <br />r <br />� Signature <br />REVISED 71/19/2014 <br />Date <br />71 �j —Z 1 C:, - �� it <br />Phone <br />�, � <br />� 6 � �:� l �_ � �� � r � t_ � �. �` , �� ,� � � � � - <br />State/Zip Phone _ <br />I � t . <br />• _ ; � , <br />City cf �ver�tt �u �ir�cs� L c�r,.;� ��ur��Lcr (�cqui;cc:) <br />!?l�ll��. <br />FEE <br />7-� C} �� �� <br />PERMIT# <br />U � � f �'� �' �� /1 <br />Ci <br />� �� <br />