20150520110432882.pdfCONTRACTOR INFORMATION:
Company Name:
Corti pa ny Address:
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SIDE SEWER
PERMITAPPLICATION
Site Contact: Yl
J Phone #:
City: <-Zip:
Email
State License #
City Bnsiness License #
Expiration Date:
PROPERTY INFORMATION:
A ddress:
Owner's Name-
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Phone ft:
El FULL LINE REPLACEMENT EISPOT REPAIR
0 PIPE BURST 0 RELINE
(PERMALINE ONLY)
DESCRIPTION OF PROPOSED WORK (Be Specific):
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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 =2� DATE
Contractor or Agent
NOWORK SUALL RECIP1 PWOR TO 113ERNI IT iSSkJANCE