Side Sewer Application.pdfOf EUAf%
C. 1390
CONTRACTOR INFORMATION:
SIDE SEWER
PERMIT APPLICATION
Company Name: '! e
Company Address:a3g36 Hwv q�
City: vri Zip: �6�1
State License # F W I
Expiration Date: 3
PROPERTY INFORMATION:
Site Contact: Y\1�1 LID
Phone #:
Email #:
City Business License # �QA (-6 7 1
Phone #: l U— 7 " ��
❑ FULL LINE REPLACEMENT ❑ SPOT REPAIR 1"` `�j 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 PERFORM I NG, SAID WORK.
I REPRESENT AND WAR'
ADJACENT PROPER I
PROPERTY. ,/
SIGNATURE
IT TO THE CITY OF EDMONDS, IF REPAIR OF EXISTING SEWER EXTENDS TO AN
VE OWNERS EXPRESS PERMISSION TO PERFORM WORK ON THAT ADJACENT
DATE 3
Z)
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE