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, <br /> . <br /> �� b ��� � �� ������ ' , ���I��� ��� <br /> C'.B�'V �F ��'���1�' �'FF�iI�PI"i" a�EaliP�E� <br /> 3200 CEDAR STREET, EVERETT, VVA 98201 <br /> 425-257-8810 - FAX 425-257-8857 —wrww.everettwa.org <br /> ��31 R.��v ,a�e <br /> PROJECT ADDRESS <br /> �,�� �� �ga�� <br /> Properly Owner td;il Address City + SlatelZip Phone <br /> Tenanl N2me(I(ihis is for a commercial 6usiness) <br /> �CG��c% /�/LC✓��'��.5 �!-.'7 7�S/.�✓Pi /✓C MGiiYSI/ I/Ci W/1' 1'�5�7✓ >'.`47��sa7 <br /> ConVaclor i�ailAdtlress � Ci,y� State2ip Phone i <br /> /�f�G G r'L �03�T aS3�if s I <br /> VJA State Contreclor License Num6er(required) City of Everett Business License�'umber(required) <br /> Work to be done: <br /> ❑ Side Sevder Repair <br /> ❑ Side Sewer Alteration <br /> ❑ Side Sewer — New Installation <br /> � <br /> �Install Back�vater Valve (outside the building) <br /> I <br /> ❑ Cap off Sewer i <br /> i <br /> ❑ Install INater Meter FEE I <br /> / 30 � ; <br /> J <br /> —. � - �-1 � � � r�eRr�n� I <br /> Signature Date � ` I �D� , I ( / I <br /> I lJ 10 � <br /> Rews=o r v�aao�a �i <br /> � <br />