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• � - ly��P 0��� �' ����`� t��'��I��,a p�� <br /> � CI'�'V C��= ��'��c�T�" �'�F��i1' ��€�efQ�:E� <br /> 3200 CEDAR STREET, EVERETT, VVA 98201 <br /> 425-257-8810 - �AX 425-257-8857 —w�nnv.everettwa.org <br /> `�a� IN����-�� ' — <br /> PROJECT ADDRESS <br /> ��.�/�. . . 1� � �`br�U( <br /> Propefly0t��ne� Mail!:Cdress City Sla!elZip Phone <br /> Tenanl Name (If thi, is for a commercial Business) <br /> /7 f�GIIrJ �'�ILG/��3�i7 f S f%J 7If/+'✓� /✓%_. MGiryS l/.1/[i W/i' I?r5�7�i .i✓s-7��So7 <br /> � Cit State2ip Phone <br /> Conlractor Mail Address - Y <br /> /�/��GGr'L Ao3�i aS3�is.f <br /> VJA Sfate Contractor License IJumber(required) City of Everett Business License Number(required) <br /> � <br /> Work to be done: <br /> ❑ Side Sev✓er Repair <br /> ❑ Side Sewer Alteration <br /> ❑ Side Sevder — New Insiallation <br /> G�Install f3ackv��ater Valve (outsicic the buildiny) <br /> ❑ Cap off Sewer <br /> ❑ Install Waier Meter FE[ <br /> �J <br /> i ��� • � <br /> -- - -- --- <br /> � _ ___ PERMITI/ I <br /> � <br /> -��SignaWre Date �� <br /> �5o�-6z�-- - � <br /> REVISlOH/79SOIC _____'__'___ ___ "" ' . " . � <br /> _ ___ <br /> _"'_.___'_-_______' _''_'__. I <br /> __ - _- I <br />