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everett <br />City of Everett <br />:: <br />CHAAT N0. <br />Si.r7� I�'- �osl���u% <br />7 - 1(�, -5/ <br />Sewer Applica#�o� and P�rmit <br />- -_�.=-- ---- <br />--_X-:____=__ <br />N0. Z$�.5i �'DATE ,a.r•�, �1, lnv� <br />Service Address 5- 7�th SC SN Utility Account No. <br />Billing Address �u-Gox ����� <br />Cily, Slate, Zip ���-y��}3 <br />Ox�ier <br />Connection by �!� ���• ��� Q�� r 2s <br />Address <br />Phone +�� u;+-d+���; --- <br />Legal Description: � <br />Lot �� - <br />Block <br />Plat ���t � �,•a <br />Unplatted Descrlption: <br />Permit F?e $ <br />Connection Charge <br />Trunk <br />Lateral <br />Total Connection Charge <br />Utility Development Fee <br />Water <br />Sewer <br />Total Development Fee <br />30.00 <br />$ <br />$ <br />$ <br />g iS2.00 <br />$ 4Gn u0 - <br />$ 352-.bb <br />Sewer Bond District n��i T�satlrau� <br />Abutting Lot Line <br />N, S, E, W n. <br />Type of Permit �_....��_p Approved By _ <br />RBtf18fk5 I5Su0d By Mwr� r 1�rLeed <br />(:us�omer Signature — <br />� <br />IMPORTANT! <br />CALL 1-800-424-5555 48-HOURS <br />PRIOR TO DIGGING <br />CALL 259-8810 FOR INSPECTION <br />SEE SKETCH ATTACHED <br />Inspection By _.���- � <br />Date Inspected � � 1y�y � <br />ir�s��i_ci ioN <br />No. 289.56 <br />