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1� <br />iliY_�SiliC.6�'JlSti1� <br />ra�vc� � cv <br />NOV 16 1967 <br />The undersigned hareby requestis the City ofU��i�LD�=aive <br />the PBY (� L <br />char8� o his/har rrater se.rvice at <br />,� GCN a S � ^+'�6%fa�'✓,L ��' The undersigned <br />/ <br />repsesents 'that the service at aaid location presently has a PAV <br />ia �ood Workia8 o�'dgr �d that. in considerstioa oi xaiver oi <br />sa'.ld charge. !or the period that undersi8ned is a�+ater service <br />customer at the above lxation, the undersigaed aBrees: <br />To maintain said PkV in good Norking order: and <br />To release the City o! E•�erett from anY 8na all <br />liability ariaing irom increased operatia8 pressur�s on <br />tY�e f5 transmission line to which t2�e abov_e f*ater <br />service is connected; and <br />?o indemnify and hold harmloss the CitT of. Everett fro� <br />installedgat cthe abovellocatioa.th'fhisiindemnityhisPoa <br />behalt of the undersigned, and the undersigned a8rees <br />to notify the city ot Everett of any chan8e �of <br />o�nership of the water service connectioa_at the above <br />'location. - - <br />1. <br />2. <br />9 <br />DATED this ��ay of <br />STATS OF iiASHINGTON) <br />33� <br />CppNTY OF � <br />I certify that I hm v_or have satistactory evidence <br />� „ - • ( , ,. � � �„N �� signed this <br />that <br />instrument and acknowledged it to be (his, <br />her, heir free <br />and voluntary act ior the uses and purPoses mention in �he <br />instrument. <br />... - <br />{d��yC. R. .,/ �-. <br />�`�``'�: ;�s��'' _;�� �'%; <br />i.•. ; .,; . � <br />.� . <br />uK'�8�1.�abrA&�.ai°P � <br />r : � i�UEL�G �'� 2 <br />c^ %y.. ol�:• � <br />� �' � �' �. . ~ 1� <br />17 , • ',yG fl <br />` 9TF OF �v! iS��.rir <br />Dated= lf'� �'s� <br />Signature oi <br />Notary Public: <br />Title: _�F° ' �' �'��'' <br />.� ---•--'-- ----'---- <br />� <br />/�' �.n.. <br />