0062_001.pdfpF EVA1041
C. J'
'NC. 13g0
CONTRACTOR INFORMATION:
Company Name:
SIDE SEWER
PERMIT APPLICATION
Site Contact:
Company Address: I eey, Phone #:
City: I14 YIAwo 0 d Z`p' 8
State License # `)ELCG HZ1�,ik�-�J
Expiration Date: i'L • l al
PROPERTY INFORMATION:
Address:
Owner's Name:
se le r,�-
Email #: �L( jz, UU LUK LO�rn
City Business License #
Phone #: L vs . 1-14
❑ FULL LINE REPLACEMENT ❑ SPOT REPAIR ❑ PIPE BURST ❑ RELINE (PERMALINE ONLY)
DESCRIPTION OF PROPOSED WORK (Be Specific):
�'l>n�� P.L ✓ice 4 inn(A LI-,
ISSUANCE OF THIS PERMIT DOES NOT CONSTITUTE PERMISSION TO WORK ON ANY PROPERTY OTHER
THAN THAT OWNED BY THE SUBJECT PROPERTY OWNER.
CERTIFICATIONS NECESSARY FOR INSTALLATION METHODS ARE THE RESPONSIBILITY OF THE
CONTRACTOR PERFORMING SAID WORK.
I REPRESENT AND WARRANT TO THE CITY OF EDMONDS, IF REPAIR OF EXISTING SEWER EXTENDS TO AN
ADJACENT PROPERTY, I HAVE OWNERS EXPRESS PERMISSION TO PERFORM WORK ON THAT ADJACENT
PROPERTY.
SIGNATURE ' DATE ! 1+
ontractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE