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SIDE SEWER
PERMIT APPLICATION RESUB
CONTRACTOR INFORMATION:
Company Name:
Company Address: hyt - (A) -
S�C, P�Ao-v
City: t!4\AV%WOO 3, Zip:
State Lice6e # se-cE�fnumw
Expiration Date: i2l-'N - 161
PROPERTY INFORMATION:
Site Contact:
Phone #:
Email #: L-�
City Bushksi Li&hs—e
Address:
2,12,b5 IL P - W Ed 46 U)
Owner's Name:
Phone #:
OCT 1 1 2019
BUILDING DEPARTMENT
CITY OF EDMONDS
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F-1 FULL LINE REPLACEMENT El SPOT REPAIR [I PIPE BURST El RELINE (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 WORK.
I REPRESENT AND WARRANT TO THE CITY OF EDMONDS, IF REPAIR OF EXISTING SEWER EXTENDS TO AN
ADJACENT PROPERTY, 114AVE OWNERS EXPRESS PERMISSION TO PERFORM WORK ON THAT ADJACENT
PROPERTY.
SIGNATURE
DATE
IACntractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
0 V E Q,V
CITY OF EDMONDS
121 5TH AV0,4UENORTH - EDMONDS, WA 98020
"P PHONE: (425) 771-0220 - FAX: (425) 771-0221
*PERNUT MUST BE POSTED ON JOBSITE*
STATUS: ISSUED ENG20190475
SME SEWER PERMIT (I -Single Famfly)
Pennit Nwnber: ENG20190475 Expiration Date: 10/31/2020
Job Address: 21235 92ND PL W. EDMONDS
APPLICANT CONTRACTOR
SELECT HOMES, LOT I SELECT HOMES; LOT 1
16531 13TH AVE W STE A] 07 16531 13TH AVE W STE Al 07
LYNNWOOD, WA 98036
LYNNWOOD, WA 98037
(425) 742-6044
LICENSE #: SELECHI I I OKN EXP: 01/02/2021
GRINDER PUMP N I PROPOSE TO REUSE SIDE SEWER E-7-1 DRAINAGE
7 REPAIR N PROPOSE TO REUSE LATERAL LID NUMBER:
sewer on private property (Lot 2) �Arith connection to stub provided vdth short plat (PLN20180053).
I
• d
•
EASEMENT IN FORMATION
PROJECT CROSSES OTHER PRIVATE PROPERTY
VERIFICATION OF RECORDED EASEMENTS COMPLETE
IADEMAIITY- The Applicant has signed an application which states helshe holds the City ofEdmonds harmlessfrom injuries,
damages or claims ofany kind or description whatsoever, foreseen or unforeseen, that may he made against the City ofEdmonds or
any ofils departments or employees, including but not limited to the defense ofany legal proceedings including defense costs and
allorneyfees by reason ofgranting thispermit.
CALL DIAL -A -DIG (1-800-424-5555) BEFDRE ANY EXCAVATION
CALL F-ORINSPECTION (425) 771-0220 EXT. 1326
24 HOUR NOTICEREQUIRED FOR ALL INSPECTION REQUESTS
APPLICATION.XPPROVAI.
THIS APPLICATION IS NOTA PEFMTUNTIL SIGNED BY THE CITY ENGINEER OR HISMER DEPUTY: AND FEES ARE PAID, AND RECEIPTIS ACKNOWLEDGED IN
SPACEPROVIDED.
Printed: Thursday, October 31. 2019
RELEA SED BY
DATE
E] FILE COPY F1 INSPECTORCOPY E] APPLICANT COPY