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WATER/SEWER UTILITY PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> 425-257-8810 - FAX 425-257-8857—www.everettwa.org <br /> 1 1219 19th Ave SE (see attached map) <br /> PROJECT ADDRESS <br /> Silver Lake Center, LLC 11624 SE 5th St, #100 Bellevue WA 98005 425.586.7700 <br /> Property Owner Mail Address City State/Zip Phone <br /> N/A <br /> Tenant Name(If this is for a commercial business) <br /> Polyqon WLH LLC SAME AS ABOVE <br /> Contractor Mail Address City State/Zip Phone <br /> polygwl863pw 053223 <br /> WA State Contractor License Number(required) City of Everett Business License Number(required) <br /> Work to be done: <br /> ❑ Side Sewer Repair <br /> ❑ Side Sewer Alteration <br /> ❑ Side Sewer— New Installation <br /> ❑ Install Backwater Valve (outside the building) <br /> ❑ Cap off Sewer <br /> I n sta I I �la�e�-�Ule�t�er`��v�`��.�`�t�� ��-���' �� <br /> FEE <br /> � � <br /> , �'`7 0( <br /> 04/02/15 PERMIT# <br /> Signature Date � � <br /> U f � ���- � `�. <br /> REVISED 11/19/2014 <br />