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everett <br />� I - / <br />% <br />City of Everett <br />Engineering Gepartment <br />Sewer Applicaf�An and PaGrmit <br />N0. -' � � � �� :' DATE _ "" � <br />Service Address � Utility Account No._ <br />Biiling Addre,s Connection Permit Fec <br />City, State, Zip Connection Fee <br />Owner (Mortgngor) � Total Fec <br />Billing Name_. <br />Conneuion By ' _ <br />Address – •� � _ Sigr�ed <br />Phone — ---- --- <br />DESCRIPTION: <br />Lot <br />Block <br />Division or Addit�on_ <br />Remarks: <br />.�-,-+-.a � s�./ 4,+ T vrc <br />�! � <( �. (�S / � ,Li;t��. .l' �i _ <br />SEESKETCH ATTACHED <br />i <br />J ai t � i <br />cmmnv � <br />Sewer District <br />Month�ly Sewer Service <br />Monthly Sew�r Constr. <br />Approved Dy <br />a�v e�,�r„���,� <br />�SSUI'(J fiy <br />Conneciion BY--- --- -- – — <br />Inspection By /(�� •J (' a (�G �o ..1 <br />Date Inspected %�,��'� �3 _ <br />