20150521143228318.pdfSIDE SEWER
PERMIT APPLICA"riON
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CONTRACTOR INFORMATION:
Company Name:
Company Address: '41
City: . Zip:
5: &,tw'j- �c.
State License # y!;>,,.,. i(z-.-
Expiration Date:
Site Contact:
Pholle
Email #:
City Business License # IV L, `/l/
PROPERTY INFORMATION:
Address: V 271�2,�6� IV
,-/�/
Owner's Name:
Phone #:
El FULL LINE REPLACEMENT SPOT REPAIR
El PIPE BURST ARELINE (PERMALINE ONLY)
DESCRIPTION OF PROPOSED WORK (Be Specific):
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 WORD.
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.
2,
SIGNATURE DATE
Contractor or Agent
NO WORK SHALL BEC1114 PRt011T0 PERM ll'ISS 1JANCIE