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i,— - <br /> � � ��0�� ������ ����I��,���� <br /> CB'��P �F ��f�REi'E' ��EE��iff SE�liifdE� <br /> 3200 CEDAR STREET, EVERETT, VUA 98201 <br /> 425-257-8810 - FfllC 47_5-257-8857 —www.everettwa.org <br /> �`�1� Q �ne.. s`� <br /> PROJECT ADDRESS <br /> E�ucf�" �,�J� ���°� - <br /> Propetty Owne� Mail Addiess Ciry � StalelZip Phone <br /> Tenant Name Q(this is for a commercial business) <br /> �"/'G//G1''%w�+.r3�iys_S�`/c7 7/lArei✓�; .�-ra�rsv,ii� w/f- ���� 3fs7�ISo7 <br /> Conirector 64ai1 Address � Cily State/Zip Phone <br /> /�/�oGGPG o3GT aS3`iss <br /> VJA State Convactor License Number(required) Ci1y of Everett Business License�umber(required) <br /> Work to be done: <br /> CI Side Sewer Repair <br /> ❑ Side Se�ver Alteration <br /> ❑ Side Sewer — New Installation <br /> i <br /> �D1�Install [3ackwater Valve (oufside the building) <br /> � <br /> I <br /> O Cap off Sewer �' <br /> � <br /> � Instail Water Meter FEE <br /> 30°� <br /> I <br /> � <br /> _ —. ___�-�-'�• 1� P[RI�IITJi j <br /> --- --� S�gn�durc Datc � I I <br /> t� �sos - �►_y _ � <br /> _ nr-ws�n nnoo�ra --------' — � --------------- -- — i <br />