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everett <br />City of Everett <br />Engineering & Community Services <br />Sewer Application and Permit <br />No. 21973 DATE !z65 b2 <br />Service Address <br />Billing Address_ <br />City, State, Zip C<Sop ZG <br />Owner (Mortgagor) <br />Billing Name <br />CHART NO. �`^' 204776 <br />Utility Account No. <br />Permit Fee <br />Connection Charge( <br />Tocal Fee <br />5� 2 A&-t <br />/?ems <br />100, 00 <br />Connection By <br />Address �G'� /���✓b�lU/JY Signed - i- <br />Customer <br />Phone — <br />DESCRIPTION: Sewer District <br />Lot 5 Block &74� <br />Monthly Sewer Service <br />Plat <br />Unplatted Description_ Monthly Sewer Constr. <br />Type Permit: /� - [� Z5 5 <br />Remarks: <br />ATTACHED <br />INSPECTION <br />Trunk— <br />Lateral — <br />Abutting Lot Line <br />N, S, E, W <br />Approved Byz - <br />City Engineer <br />Issued By, <br />Inspection By A <br />Date I nspected ZJ7 % <br />No. 21973 <br />