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evereri <br />e <br />City of Everett <br />Enginee�ing Department <br />Sewer Application ar�d Permit <br />NO.f�--�U�7✓ DATE <br />ServiceAddress S�9 5� �rs �V <br />Billing Address <br />City, State, Zip <br />Owner (Mortgagor) <br />Billing Name <br />Connection By — <br />Phone. <br />DESCRIPTION: <br />Lot _ <br />Block — <br />Division or Addition <br />Utility Account Nc.._ �- '�' f –' �' <br />Connection Permit Fee <br />Connection Fee <br />Total Fee <br />Sisned <br />Customer <br />� <br />Sewer Qistrict__ <br />Nlonthly Sewer Service <br />Monthly Sewer Constr <br />SEESKETCH ATTACHED __ <br />Approved By - <br />Citv Engincur <br />Issued <br />Connection Ey <br />yor l,�/�P��t) <br />Inspection By a �— <br />Date Inspected <br />