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everett <br />�; <br />�- <br />� <br />:� <br />City of Everett � � � � � � g � �� � a <br />� �., ,- �., <br />'J �C ..-r .� �A �;. :e. ��._ .-; 4 � J <br />.r1. m .^.�l <br />Se�nrer I�p�ilicati�n��nd�Perr��t <br />� J .�' ._J '�'�tl � .'l r �y'. � ? ^ �7 <br />�`" j {? : '^� . _ r � � �: %?� ,� :� � <br />� - -- <br />NO. �L%��� DATE � «�?� ,QQn _ <br />Sarvice Address <br />Biiling Address <br />City, State, Zip � <br />Owner , , <br />Connection by <br />Address <br />Phone <br />Legal Description: <br />Lot <br />Block <br />Plat <br />Unplatted Description: <br />Type of Fermit <br />Remarks <br />IMPORTANT! <br />CALL 1-f00-424-5555 48-HOURS <br />PRIOR TO DlGGING <br />CALL 259-8810 FOR INSPECTlON <br />SEE SKETCH ATTACHED <br />CHART N0. <br />Se��f % �drf,�t� f'r-iZ-�� <br />Utility Account No. <br />Permit Fee $ _�gtgg <br />Connection Charge <br />Trunk <br />Laterai <br />Total Connection Charge <br />Utility Development Fee <br />Water <br />Sewer <br />Total Developmont Fee <br />Sewer Bond District �, <br />hbutting Lot Line <br />N, S, E, W �Q' <br />Approved By <br />$ , — <br />� 688 00 — <br />Issued By � <br />, .4=:�� ._ . <br />Customer Signature <br />ft. <br />Inspection By •�g«�`�/' <br />Datelnspected / �—y/ — <br />ir�s�Ec � io�. <br />No. 2792 � <br />