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i <br />�Y`�'VfLp`a `� V�'�fF��i��Y`�' ,�1�'�'{LU�k�'ll-'��b� <br />Ci�'Y OF EVERET�' f�EF2Mi i:�E�t!/IC�� <br />37_00 CEDAR STREET, EVERETT, WA 98201 <br />425-257-8810 - FAX 425-257-8857 — uww,v.everettwa.org <br />.3�(j �+�U C ILCF�GL �-2 �a� ✓ L?/c'�'�.�['r �fr � o � <br />PROJECT ADDRESS <br />os E ..3� �cC�u �^� r..� L�i�c��.�r�r- Wn 5'�Zo � 5�2� s�� _� <br />Pwpeity C�vner ldaJACdress Cdy Slate/Z�p r'hore li <br />� � � � I <br />I <br />� <br />Tenant Narne Qf Ih�s is for a commercial busmess) <br />N[�2o (�,�c�� w� cPo �c�sa,�i so�,o, w�a . 9�29 i 2oa -4c� _ r�9 2 5' <br />CortraCtOr I.la�lAddcess Gty State!Zip Phone <br />�I �2o PL��� o� s __ <br />\%w4\ S!ate Cent�ac'or Gce��se Nwnber (rzquired) <br />Work to be done: <br />O Side Sewer Repair <br />❑ Side Sewer Alteration <br />❑ Side Sewer — New Instailation <br />� Install Bar.kwater Valve (outside the building) <br />❑ Cap off Sewer <br />❑ Install Water fvieter <br />g_ 22- �s <br />Signaturc Da�e <br />nEv�se� tv�?r.ara <br />osz-x�� <br />Cdy ef Gverelf P.usiness License Num6er (required) <br />FEE - <br />30 �� <br />PEar�rr� <br />ui50y�-[0� <br />