20160111104132.pdfCONTRACTOR INFORMATION:
SIDE SEWER
PERMIT APPLICATION
Company Name: W Site Contact: OM I P Qch
Com an Address•Phone #:
.._ ...
Cit Zip: OI 8 I p Email
vv State License #City Business License #
Expiration Date:
PROPERTY INFORMATION:
Address:
Owner's Name: n r
" Pd'�"
Phone #:
❑ FULL LINE REPLACEMENT DdSPOT REPAIR ❑ PIPE BURST ❑ RELINE (PERMALINE ONLY)
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 Q
Contractor or AgW
NO WORD SHALL BEGIN PRIOR TO PERMIT ISSUANCE