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PERMIT APPLICATION
CONT TACT 'JII INFOI ATION:
Company Name: Site Contact:
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Company Address: Phone #�
City: r' Zip` Email #;
State License # City Business License #
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Expiration Date:
PROPERTY INFORMATION:
Address:
Owner's Name: 7oOi ?
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.... _.........
Phone #:
❑ FULL LINE REPLACEMENT REPAIR [-IPIPE BURST ElRELINE (PERMALINE ONLY)
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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 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
or Agent