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��A�,��`'� �����ll� ������,�`���if�' <br /> CeTV OF �VERE�'T' F'ERNIST' ��I�!/IC�S <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> 425-257-8810 - FAX425-257-8857-www.everettwa.org <br /> �.5/ Z gr'cr,�� A �u2 � �Pd`�tYT-� `�Z�}'G, <br /> PROJECT ADDRESS . <br /> O�o'�-41"'� l�ou�Q.r <br /> Properly0wner MailAddress . City State2ip Phone <br /> Tenanl Name(If lhis is for a commerciai business) <br /> �v� ) �l � �c rh t n `P 0 5�`P� �ue�%�z.}� I.�� �$2tXo .— <br /> COnl�aClOr MailAddress Cily State2ip Phone <br /> ��}f� �P,� l`j�J7 MS c7y 7703 <br /> 1NA Slale Conlractor License Number(required) Cily of Everett Business License Number(required) <br /> Work to be done: <br /> ❑ Side Sewer Repai; <br /> ❑ Side Sewer Alteration <br /> ❑ Side Sewer- New Installation <br /> Install Backwater Vaive (outside the buiiding) <br /> ❑ Cap off Sewer <br /> ❑ Install Waler Meter <br /> FEE� <br /> � DU <br /> , i <br /> `��-__���-P -_- <br /> 7/Z-p/� PFRMITk <br /> Signalurc � '--_ Lf�'° � � �`�U� ' �� <br /> Fa�SEu i vivmw <br />