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everett <br />� / , � _ _. <br />� <br />;�.��� /i/�� <br />City of Everett r � <br />�. <br />Engineering Oepartment <br />Se�ver Applicai�ion ar�d Permit <br />N0. ;�-��� 1 � ;� � DATE <br />, <br />Service /lddress . ' ` <br />Billing Address — <br />City, State, Zip '' <br />Owner (Mortgagor� <br />Billing Name -- <br />Connection By <br />Address <br />Phone <br />DESCRIPTION: <br />Lot _ <br />Block <br />Division or Addition <br />Remarks: <br />�_ . , i. .�.;, <br />y' `Gz� ... '� r `' F�� � �o� 7 : <br />., �� � s � .�t <br />�,— <br />SEE SKETCH Al'TACIiED <br />Utility Account No._ <br />Connection Permit Fee <br />Connection Fee %�D7��G� <br />Total Fee <br />� <br />Sewer District / <br />Monthiy Sewer S�rvice <br />Monthly Se�ver Constr. <br />. <br />Approved By <br />�, City <br />— I,sued By <br />Connection By— <br />Inspection By � � n�f��`^� <br />Date Inspected__���f�� <br />