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. �• <br /> � Jl��ll Y � ��II nYNVIf 1'' ���, F"l11\Y�f�,��Y V <br /> GBT'Y �F �Vf�R��'�' �'���ill���' ���dB�f��S <br /> 3200 CFDAR STRLET, EVERETT, WA 98201 <br /> 4?_5-257-8810 - FAX 425-257-8857 — www.everettwa.org <br /> , �l IGN�/' <br /> ����! j c' ✓ r <br /> PROJECTADDRESS <br /> _1 �/�1 _W�Q �J' 4/'�� --- — �- �G���j").�.—'✓� --- <br /> Property0wner NailAddress C�ty Slale/Lp Phone <br /> Tenant Name Qf this is for a commercial busmess) Y� <br /> _�' ���� 1-� � /� 55�f I A <br /> �_� ' �l r�1. l Yl 't,'� E vE�l'C� �� 1 Ff�-- --- <br /> Contraclor� Vail�l4dres5 � Ci;y 5tale2ip Phone <br /> C'��'lr'B� ►� �� MS ���--�a�— <br /> WA Slale Contractor License Number(required) City ol Gverett Business License Numbe�(required) <br /> Work to be done: <br /> ❑ Side Sewer Repair <br /> ❑ Side Sewer Alteration <br /> ❑ Side Sewer �- New Installalion <br /> � Install f3ackwater Valve (outside ihe building) <br /> ❑ Cap ofi Sewer <br /> ❑ Install Water Meter -- --- — <br /> FEE <br /> �� o� <br /> � �� PERMITJt -- --- <br /> �— — - --- ---- <br /> 6igna�ure Date U 150�-005 <br /> r+e�isre nnsoaia <br />