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APPL. / I �YAPPLICATION FOR SERVICE 5t7i+vlc17 N2 1 163 <br />No/mil G>Jr" CITY'OF VERETT WATER DEPT. c,nTC NTrORDE, <br />n FIXED �l c19 <br />DEPOSIT s �I�CX <br />J/ �'/ No. <br />SERVICE IBYADDREIBI n - ��� SLK.__LOT ADD <br />NER y CONTRACTOR_ <br />11Qcc7 FLAT <br />-MJQERSD-SERVICE <br />I HEREBY APPLY FOR THE USE OF WATER IN ACCORDANCE WITH THE i.'�'f'',-�jL—Y,•i <br />ORDINANCES AND POLICIES OF THE WATER DEPARTMENT NOW EXISTING OR AS SAME MAY BE HEREAFTER CHANGED. SIGNED: <br />MATERIALS <br />'AIN. <br />I I IN. <br />I I IN. <br />P ICE <br />AMOUNT <br />PIPE COS GALV. -- STEEL_ <br />CORPORATION <br />CURB C6clr OT <br />SERVICE BOX LASTI <br />METER VALVE_ <br />METER NO. TYPE: Hi <br />— <br />METER BOX CONCRETE SMALL LARGE <br />aON <br />DATE INSTALLED: _ I ❑ OFF SUB TOTAL <br />�[ <br />COOK LABOR AND EQUIPMENT RENTAL HOURS <br />RATE <br />-�� -A/ --- <br />�� <br />I <br />-- -�-3 - <br />' ' a <br />�- <br />-- --- - ----- ----- <br />TOTAL <br />REMARKS: /JA <br />