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UTILITY PERMIT APPLICATI�N <br />CITY OF �VERETT PERMIT SERVICES <br />3?_00 CGDAR S�REET, EVEREiT, �NA 98201 <br />425-257-A810 - F�X 4?5-257-a857 — v✓vrro everetttva.org <br />_ 2g12 I � _Sr. --- <br />PROJECT ADDRESS <br />U�7 � O�S <br />� �,�C� �l <br />l��_ �-�'� 2� I Z�� ST�-- -��r�,��� �--L----- <br />I'[operty Ovmer IZail Address ('i'y Sl;tle!Z o Phone <br />n i <br />. '` _ .—. —____ ___._ <br />l^npn� PJomc Qf �hiz is Inr a wrnriarcial husinessj <br />120b �--�iV <br />— r-.--�-- - <br />Conl�ador MmlAddress <br />:h'A S!ate Contraclor License Number (required) <br />Work to be done: <br />[� Side Sewer Repair W I,Q/1 (�,Q/l/ <br />❑ Side Sewer Alteration <br />❑ 5ide Sewer — New Installation <br />City StatelZip Phone <br />����_—__-- _— <br />- Citv of Evereit Business Llcense Number (required) <br />❑ Install Backv�atcr Valve (outside the building) <br />❑ Cap off Sewer <br />❑ Install Water Wleter <br />- - 9 �"9 _/.3' <br />—� , ignalure / - - Dale <br />e:Lvrt=o i inacn.a <br />a <br />rrF <br />��� ,�� <br />PERh1Ti tt -- <br />�� l �1' D l� � <br />�b � <br />