20150615093618827.pdfCONTRACTOR INFORMATION:
SIDE SEWER
PERMIT APPLICATION
Company Name:Site Contact:
<..., .,. `r ,
Compa
-
Company Address: 1
3 Phone #:
City: Zip:
Email #:
State License #
City Business License #
Expiration Date:
PROPERTY INFORMATION:
Address:
Owner's Name: I'-
Plione
❑ FULL LINE REPLACEMENT \f4 SPOT REPAIR
F1 PIPE BURST ❑ RE, LINE (PERMALINE ONLY)
Fr
DESCRIPTION OF PROPOSED WORK (Be Specific):tF
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 WAR -RANT TO THE CITY OF EDMONDS, IF REPAIR OF EXISTING SEWER EXTENDS TO AN
ADJACENT PROPERTY, I HAVE OWNERS EXPRESS PERMISSION TO PERFORM WORD ON THAT ADJACENT
PROPERTY.
DATE
SIGNATURE
Contractor or Agent
P40 WORli, SHALL P11,1011TO Plli'R.1%1117ISSUAINCE