Side Sewer Permit Application 8912 192nd Street SW Binder Veilleux Home 6.8.2020of t: DAt
wc. 164"
SIDE SEWER
PERMIT APPLICATION
Company Name: L� T. Yt 1W(frl tlrrcl- Site Contact: C► .4-
Company Address:
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City: —
Zip: (-
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Email #: \i ers �m� iJ_
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State license so CTO�
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CitN Business License #
Expiration Date: - _
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PROPERTY INFORNIATION:
Address: efi
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Owner's Name: Drb-A
Phone N:
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❑ FULL LINE REPLACEMENT ❑ SPOT REPAIR ❑ PIPE BURST
DESCRIPTION OF PROPOSED WORK (Be Specific):
❑ RELINE (PERNIALINE ONLY)
ISSUANCE OF THIS PERMIT DOES NOT CONSTITUTE PERMISSION TO WORK ON ANY PROPERTY OTHER
THAN THAT OWNED BY T 1IE 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. I
SIGNATURE. �� 1 i j--- DATE. 6 y —2�
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
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