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��'����'�-� ����tl�� �a���p�l�e�o���� ; <br /> C:I 0�°� C�F ��,f��F I�' t��PEVyi'� SEF���'I�:F� ! <br /> 37_00 CEDAR STREET, EVERETT, VV/, 9u201 ; <br /> 425-257-8810 - FAX ?25-25i-8857 - wv,v� everettwa.org � <br /> i <br /> —13�� Co 11�. , �,,�L i <br /> PROJECT ADDRE S i <br /> �JzrC�- E ..��1 �18�c�1 <br /> Property Owner Mad Address Cdy Slate/Zip Pho�e <br /> Tenant Name (iith�� i, for a commercial business) <br /> I <br /> �'/'o/% P%ur-+�3�ny S`/'7 7�1r'ru i✓' M��vSv�ile� w/?- j����✓ .75s7'�s�7 <br /> Coniractor I�Aail Address � City State2ip Phone <br /> /�P�iGGPG �G.�G% GS.3�/SS <br /> VJA State Contractor License Number(required) Ci�y of Everetl Business License Num6er(required) i <br /> I <br />' I <br /> Work to be done: i <br /> ❑ Side Sewer Repair <br /> ❑ Side Sewer Alteration i <br /> ❑ Side SeLver - New Installation I <br /> (i?]�Instail E3ackvaater Valve (outside the building) <br /> ❑ Cap off Sewer I <br /> ❑ Install VVater Meter � <br /> FEE i <br /> i 30�� � <br /> II � — 11J— U �`� _ PERh11�T i �i <br /> SignaWre Datc � � � �O� �2� I <br /> tJ �/ ' <br /> i <br /> .cn�rseo+v�caora _ I <br /> " I <br />