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W. o. FORM ] ,40'�v/ /O <br />Aect. No.... ........ <br />CITY OF EVEREM — Water Dopt. <br />Appliea..on No ... PZ.A 12........ Date........ 3.-... .` .............. .... 19........ <br />Install......._.._..-.._.__....., inch water service pipe <br />Owner....... ... _................................. ...................................................... <br />Address..._.._.._....L.O....'J.....-._.._%..!6. y—......................... ......__............._. <br />Lot.................... ...... _ ...... _......... .............. Block No ............ ...... _..................... ... <br />Addition........................ _............................. __......_............._..........._.........._.. <br />Contractor..._.._. ..... _ <br />Remarka..Q (�_.w....._.._.._.._........_..._............`......_....._...... ... .... ...... _. <br />Amt.... ................................ Rec. No .... _..... ............. _...._............................. <br />S-iperintendent/ <br />-jq.17 <br />ShopRemarks ............ ... ...... ........... _...... .... .._......... ........ ........................... _. <br />........................._............... ..... .......... ................ ............... ....._.......................... <br />... <br />WorkCompleted ............... _.............................................._................................... <br />Fore <br />