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�verett <br />I <br />City of Everett <br />Sewer Application and Permit <br />NO. 2$O4O DATE <br />Service Address � a� � Utility Account No. <br />Billing Address <br />City, State, Zip <br />Owner — <br />Connection by <br />Address . <br />Phone — <br />Legal Description: <br />Lot <br />Block <br />Plat <br />Unplatted Description: <br />Bth Ave NE <br />Seettle, t9n 98115 <br />Nazk Winslom <br />Day +G liigAt Plumbing <br />Type of Permit _ <br />Remarks — <br />IMPORTANT! <br />CALL 1-800-424-5555 48-HOURS <br />PRIOR TO DIGGING <br />CALL 259-8810 FOR INSPECTION <br />SEE SKETCH ATTACHED <br />CHART N0. _ <br />�,, i�.�t� <br />�2��3 K� <br />Permit Fee $ <br />10.00 <br />Connection Charge <br />Trunk $ <br />Lateral t I .' $' . <br />Total Connection Charge�un,$,;: <br />.11!!:i' :';i.��'I <br />Utility Development Fee �_�_� ; i.il.l�i <br />Water $ <br />Sewer $ <br />Total Development Fee $ <br />Sewer Bond District <br />Abutting Lot Line <br />N, S, E, W — <br />Approved By _ <br />Issued By <br />Customer SignaWre <br />Inspection By ��" � <br />Date Inspectad ��-"z� �y� <br />INSP[CTION <br />rvo.280�Q <br />ft. <br />