20150825102742.pdfSIDE SEWER
PERMIT APPLICATION
CONTRACTOR INFORMATION:
Company Name: ;&:5'l
�Site Contact:
Company Address: Phone #c _-
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City. Zip , Email #:
State License ft �zG�t Z City Business License #
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Expiration Date:
PROPERTY INFORMATION:
Address:
Owner's Name.
Phone #: ✓� /
❑ FULL LINE REPLACEMENT ❑ SPOT REPAIR ,� PIPE BURST ❑ RELINE (PERMALINE ONLY)
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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 C` 1'OWNERS 111MR PERMISSION TO PERFORM WORK ON THAT ADJACENT
PROPERTY.”
SIGNATUREeDATE
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Contractor or Agent
9° �i1101m] '11,111,19fell