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UTILITY PERIVI�T APPLIC/�TION <br />CITY OF EVERETi PERMIT SERVICES <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />425-257-8810 - FAX 425-257-8857 — www.everettwa.org <br />Z�Z� M�c�ison s� <br />PROJECT ADDRESS <br />�.dti S�- <br />Praperty Owner <br />Mail <br />Tenant Name (If this is for a commercial business) <br />City <br />State2ip <br />�2 12«h�� 1GosS ikNl IK�«F �� �l�a i�lr�.ry Ur� ��I6� 5�z r <br />Coniraclor Mail Address City StatelZip Phone <br />� O�o �SC l Z2 P,YZ <br />WA Sla�e Conlrector License Number (reGuired) <br />Work to be done: <br />,�., Side Sewer Repair <br />❑ Side Sewer Aiteration <br />❑ Side Sewer — New Installation <br />❑ Install Backwater Valve (outside the building) <br />❑ Cap off Sewer <br />❑ Install Water Meter <br />S� /s <br />RcV15FU 1 f/19 c014 <br />Phone <br />n 3 77 z �-` <br />Ciry of Everr•tl Business License Number (required) <br />FEE <br />30°� <br />PERMIT# <br />U i5o5-o23 <br />