REVIEWED BLD2021-0070_SIDE SEWER APP_4.8.2021_3.12.15_PM_2135834ENG2021-0161
SIDE SEWER
PERMIT APPLICATION
CONTRACTOR INFORMATION:
Company Name: Select Homes, Inc. Site Contact: Gary Klick
Company Address: 16531 13th Ave W. Ste. A107 Phone #: 206.730.0670
City: Lynnwood Zip: 98037 Email #: gary@selecthomeswa.com
State License # SELECH1110KN City Business License # NR-026591
Expiration Date: 12 31 21
PROPERTY INFORMATION:
Address:
1006 Walnut St.
Owner's Name:
Select Homes, Inc.
Phone #: 427.742.6044
❑ FULL LINE REPLACEMENT ❑ SPOT REPAIR ❑ PIPE BURST ❑ RELINE (PERMALINE ONLY)
DESCRIPTION OF PROPOSED WORK (Be Specific):
Connect to new sewer stub
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 4.8.21
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE